From Wellness to Medical Treatment?
Can Mindfulness Evolve From Wellness Pursuit to Medical Treatment?
Roughly a third of all adults in the United States have high blood pressure, a major risk factor for heart disease and stroke. It’s a condition that can be largely controlled with diet, exercise and medication, yet the Centers for Disease Control and Prevention estimates that only about half of the 75 million people who have high blood pressure manage to keep it in check. In November, Eric Loucks, director of the Mindfulness Center at the Brown University School of Public Health, and colleagues published a study in Plos One, a science journal, that put forward a possible solution: an eight-week mindfulness-based program.
Their experiment seemed to show that such intervention could help those with high blood pressure lower it substantially and maintain that improvement for at least a year. Funded by the Science of Behavior Change program at the National Institutes of Health, it was also more evidence that the medical establishment is starting to consider mindfulness — originally an Eastern spiritual practice that Western marketers have co-opted in recent years to sell everything from yoga leggings to Ford Explorers — a legitimate form of treatment. The Plos One paper was one of more than 7,000 studies published last year that included the word “mindfulness,” according to the U.S. National Library of Medicine; in 2007, roughly 70 scientific articles were published on therapeutic uses of the practice, JAMA noted the following year. “The fact that almost every single day there’s a study coming out showing the benefits of mindfulness training creates this level of confidence that this is valuable,” says Michael Mrazek, director of research at the University of California’s Center for Mindfulness and Human Potential.
But in order for physicians to be able to “prescribe” mindfulness as a therapy, it would help to be able to quantify it. Compared with a pill, say, mindfulness — often described as the practice of paying attention to your present experience without judging it, sometimes but not always through techniques like meditation — is far more difficult to define. What constitutes a “dose”? And how can you be sure people are getting it? Despite the growing excitement about the potential for mindfulness to treat or supplement therapies for almost any health problem imaginable — including depression, smoking and chronic pain — without the same risk of side-effects that many pharmaceuticals have, studies on its impact have generally returned mixed results, perhaps in part because they have been experimenting with slightly different versions of it in different contexts.
Loucks and his colleagues wondered whether a mindfulness regimen designed specifically to reduce blood pressure would work better than general mindfulness programs, which previous studies have shown to have mixed results when it comes to lowering blood pressure. They started with one of the most widely used mindfulness curriculums, a program called Mindfulness-Based Stress Reduction, first developed in the late 1970s at the University of Massachusetts to help hospital patients manage chronic pain. Participants typically take a group class two and a half hours a week for eight weeks, in which they learn to train their attention on their present experience with equanimity by using techniques such as yoga and meditation; they are also supposed to practice mindfulness skills at home for at least 45 minutes, six days a week, and take part in an orientation session and a daylong retreat. Loucks focused each weekly mindfulness session on a behavior that contributes to high blood-pressure, like inactivity or eating too much sugar and salt. One week, participants practiced mindfully eating something sweet or salty in class: Loucks asked them to describe how they felt emotionally and physically before, during and after taking a bite; then they did the same for foods from a variation on the Mediterranean diet.
Forty-three volunteers with high blood pressure completed the one-year trial. To measure the effects, the researchers gave their subjects questionnaires to gauge how well they identified and controlled their emotions as well as tests to assess their ability to pay attention to a task before the program began and again three months, six months and 12 months after it ended. The study also evaluated its subjects’ physical-activity level, diet, body mass index, perceived stress, alcohol consumption, medication adherence and blood pressure. Those who weren’t following official guidelines on heart health at the outset all showed improvements when it came to physical activity, diet and alcohol consumption; all participants reported lower stress. On average, a year later, the study participants had lowered their systolic blood pressure by six points and their diastolic pressure by an average of one point, a significant overall improvement.
But the study also illustrates the difficulties inherent in trying to judge the health effects of any psychological intervention. The scientific method, in comparison, is well suited to testing drugs like blood-pressure medications: One group of trial subjects gets the medication, another gets a placebo and neither the researchers nor the participants know who gets what until the clinical trial is over, eliminating the possibility that their expectations about the drug’s effectiveness influence the results. In other words, the conditions for each group are exactly the same, except for the chemical makeup of the pill they are ingesting. In theory, then, any difference in health outcomes between the groups must be a result of that difference in chemicals.
It is impossible, though, for persons practicing mindfulness not to know whether or not they are doing it, so how do you create a “placebo” for a control group? Loucks’s study compared participants with themselves before and after the mindfulness training, but it’s impossible to be certain whether the training itself caused the observed changes. It could be that simply meeting in a group for two hours a week (or 10 minutes a week, for that matter) improves health. To find out, you would need to convene such a gathering for the same length of time as the mindfulness training group and then “give them something to do,” Loucks says. “What is that content?” — taking a health class? — “and is it messing with our question?” To put it another way, can you say what the precise difference is between the mindfulness training and that health class, which is the behavioral equivalent of the chemical difference between a drug and its placebo, that accounts for a difference in outcomes?
That difference, the aspect of mindfulness that impacts health, may become clearer as researchers develop increasingly specific mindfulness-training programs and test them on larger, more diverse groups of people. In Loucks’s study, as in many mindfulness studies, most of the participants who responded to advertisements seeking volunteers were white, college-educated and by definition interested in trying the practice, so it’s not clear if the results apply more widely. Loucks is currently running a randomized trial of his mindfulness-based blood-pressure program with 200 volunteers; those in the control group work with a physician to manage their blood pressure and receive a blood-pressure monitor to keep at home along with training on its use, which has been shown to improve how well patients manage their condition. (Not having all the answers yet doesn’t mean we shouldn’t act; health officials approve many drugs without knowing for whom they will work best, at what dose and why, or what their long-term effects might be, variables that even the most rigorous trials can’t always determine.)
It may be the case, too, that scientists need to develop new metrics to analyze a potential medical intervention that’s rooted in ancient Buddhist philosophy. “Buddhists didn’t talk in terms of anxiety and depression,” the language clinicians use to define a collection of symptoms, like insomnia or diminished interest in activities, diagnosed through standard survey questions, says Judson Brewer, the director of research and innovation at the Brown Mindfulness Center. “They used words like ‘clinging’ or ‘attachment.’ That’s what we’re talking about, getting caught up in our experience — that’s where suffering comes from.” Alleviating that “stickiness,” Brewer says, is what mindfulness is actually supposed to do. So, to tell if it’s working, “we need a stickiness measure.”