Meditation for the treatment of depression: Theory Assessment

Meditation and mindfulness have garnered in popularity in recent times - Amidst our busy and stressful lives, individuals are plagued with societal expectations and stresses, the ability to find some quiet and some space has become a valuable tool in the 21st century. The simplicity and effectiveness of medication is part of the appeal, in addition, the non-invasive administration compared to other medications and traditional therapies. The application of meditation as a tool for the treatment of depression has gained popularity amongst practitioners and professionals who deal with patients suffering from psychiatric alignments. Two research papers that look at the efficacy of meditation techniques are examined below.

The first research paper titled “Mindfulness Based Interventions in psychiatry” [1] investigates the effectiveness of Mindfulness Based Interventions (MBI) for the treatment of psychiatric disorders. 

The research primarily looks at Mindfulness Based Interventions, or MBI in the form of Mindfulness-based Cognitive Therapy (MBCT). MBCT programs are designed to be 120-150 minutes per week, for the duration of 8 weeks. MBCT focuses on two main components: (i) formal meditation practices which includes seated meditation sessions, mindful movement (example: walking, yoga) and the body scan method, a technique used to bring attention to bodily sensations starting at the feet and progressively moving up towards the head and neck. (ii) informal meditation practices whose objective is to incorporate mindful awareness in everyday activities such as mindful eating, or mindful brushing of the teeth.

The application of MBCT has been shown to reduce the risk of depression relapse via cognitive, psychological, and neural mechanisms. Stressful life events or other triggers in everyday life can lead to recurrent negative thought patterns such as depressive rumination, judgment and anxiety which may lead to depressive relapse or other psychiatric symptoms. Mindfulness places emphasis on identifying these thinking patterns as they arise and viewing as temporary thoughts that are not facts or realities to be identified with or reacted to. The ability to accept without judgment and adopt a non-reactive attitude is one of the key mechanisms for the reduction of negative thinking patterns.

The paper provides evidence supporting the use of MBCT for the reduction of depressive relapse and includes a meta-analysis that cites four randomized controlled trials of patients with at least three depressive episodes. The evidence found that MBCT reduces the risk of relapse compared with ‘Treatment as usual’ (TAU) or placebo control groups. The MBCT+TAU patient group showed a 32% relapse rate, compared to the TAU, control group of 60%. There is strong evidence to suggest that MBCT is effective as a maintenance antidepressant medication in prevention of major depressive relapse.  One caveat of the research shows that MBCT studies that include active-control groups result in mixed findings, as MBCT may not be the most effective tool for preventing relapse, especially compared to other active psychosocial interventions.

Following MBCT treatment, participants self-reported improvements in mindfulness, reduced rumination, reduced worry, improved meta-awareness, increased self-compassion and reduced emotional reactivity. MBI also helps train the individual to develop a different relationship with their thoughts by developing the skills to notice one’s thoughts, separating the perspective of the self, and creating self-awareness.

Finally, the mechanism for enhancing emotion regulation strategies, through repeated meditation, allows participants to develop body awareness through self-regulation and emotion regulation. In addition, cultivating the nonjudgmental state increases the participants ability to respond and manage stressful events.

In summary: “Despite this relative short history, MBIs have garnered considerable support for their efficacy to treat psychiatric disorders. Numerous research investigations have shown that MBIs are efficacious for reducing depression relapse and treating depression symptoms.

In addition, these interventions reduce symptoms across psychiatric disorders with mounting support for anxiety disorders, bipolar disorder, eating disorders, and substance use disorders.” [1]

The second research paper titled “Meditation Programs for Psychological Stress and Well-being: A Systematic review and Meta-analysis” [2] investigates the effectiveness of meditation programs for improving stress-related outcomes. This piece of research aggregates the results from studies dating up until June 2013 with Meditation as the primary tool. 

The research looks at studies with the following criteria: Adult population (18

years or older) exhibiting medical (heart disease, cancer, diabetes, hypertension and HIV) or psychiatric (anxiety, depression, stress and insomnia) condition, ignoring healthy individuals.

Various types of meditation techniques are cited, including: (i) Mindfulness-based (MBSR, MBCT, Vipassana, Zen, other), (ii) Mantra-based (eg: Transcendental Meditation, other) and (ii) other forms of meditation. A total of 18,753 unique citations including 47 trails with 3,320 participants met the above criteria.

In addition to Mindfulness-Based Cognitive Therapy (MBCT) the other techniques mentioned include Mindfulness-Based Stress Reduction (MBSR) an eight-week course developed 40 years ago is similar to MBCT but instead of addressing a specific conditions or vulnerabilities provides techniques for “managing negative thoughts”. MBSR can be perceived as a generic technique for combating stress arising from a variety of life events, or a more generalist approach.

Vipassana, the oldest Buddhist meditation practice, is a slightly different form of meditation that focuses the command of non-reaction and freedom from the ego. The practice of Vipassana is used to develop the awareness of the interconnection between what happens in our minds in reaction to what happens to our bodies. Whether an individual experiences boredom, anger, pain or anxiety, training the mind to disconnect and be more patient is at the essence of Vipassana. 

Zen meditation, sometimes known as Zazen, is a deliberate effort to focus on the ‘now’. The focus of the mediation can be on the breath, or on the sensations of sitting, or external sensory input (eg: sounds, tastes, touches, smells) – Zen meditation is to acknowledge the experience without judgement. Example “the purpose of eating dinner, is to eat dinner”.

Another form of meditation discussed is Transcendental Meditation (TM), or mantra-based meditations. TM is a silent, mantra-based form of meditation, where practitioners repeat a manta in the mind and come back to the mantra when thoughts arise. The idea is to force the mantra to transcend the process of thought.

The findings of this research paper are measured by effects on the following categories: Anxiety, depression, stress, overall affect, quality of life, attention, sleep, substance use, pain and weight. Overall, it was shown that the adoption of a mindfulness meditation program demonstrated moderate evidence to improve depression, with an Effect Size (ES) of 0.3 with 95 percent confidence intervals.

In summary: “Mindfulness meditation programs, in particular, show small improvements in anxiety, depression, and pain with moderate evidence, and small improvements in stress/distress and the mental health component of health-related quality of life with low evidence when compared to nonspecific active controls. Mantra meditation programs did not improve any of the outcomes examined, but the strength of this evidence varied from low to insufficient.” [2]

Both studies illustrate the efficacy of a Mindfulness and Meditation practice for the treatment of depression. The ability to disconnect from one’s thoughts and be less reactive to external and internal stimulus can have a positive impact. Due to the wide-ranging benefits and the variety of meditation methods, studies suggest that meditation and mindfulness is a non-invasive and easily administered tool for the improvement of general

well-being and mental health.

References

[1] B. Shapero, J. Greenberg, P. Pedrelli, M. de Jong and G. Desbordes (2018)

Mindfulness-Based Interventions in Psychiatry

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870875/

[2] JAMA Intern Medical - M. Goyal, S Singh, E Subinga, N Gould, et al (2014)

Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142584/

MRI Results

Popped by my Orthopaedic specialist to retrieve results of the MRI on my Left Ankle. "You have completely torn your ATFL". The ATFL, or Anterior talo-fibular ligament is one of the three ligaments supporting the ankle. Not surprisingly, the specialist recommends surgery. My heart drops instantly. It's not the first time a specialist has recommended surgery, my ankle, my shoulder, my ankle again. Ignoring this recommendation, I begin the long and tedious path of physiotherapy and rehab.

Two months since the injury, the swelling is slowly reducing and it no longer hurts to walk. I also have mild scoliosis, where my spine cures slightly to the left. Most likely from poor working at home ergonomics. 2021 is definitely the year for self-care.

2021, come at me

The extension of dining restrictions coupled with the official cancelation of New Year events, meant that all New Year's celebrations would be confined to small gatherings on private premises. Despite the colder-than-usual weather, I decided to take advantage of my rooftop and host New Year's at mine. Equipped with enough meat and blankets to feed and warm a small village we managed to usher in the new year by watching the midnight fireworks in Sydney (at 9 pm HKT) followed by the midnight "virtual" fireworks in Hong Kong. The night was chock full of eating and wine ending up with an intense session of board games (read: Nertz).

Despite only having 6 people over, the combination of grilling, baking, boiling left a solid amount of clean up work. So after the crowd had left, I spent a good solid 45 minutes tidying up, cleaning wine glasses, wiping down the oven and vacuuming up crumbs. The moment of pause, silence and reflection. The post-party clean up reminded me of when my parents would host New Years back in Sydney and we would spend the hour or so after tidying up, drying dishes, wiping down tables, cleaning up the Eski. 

In any case, the year that was 2020, has finally come to a much needed end. I start 2021, with a fridge full of leftovers, a half eaten packet of Tim Tams and boundless expectation. It's time to shine, 2021.

One week of the year

Hong Kong is classified as a 'sub-tropical' island. Which roughly translates to 3 months of stinking hot, humid weather, 3 months of moderately hot weather, 5 months of temperate weather, 1 month of cool weather during the winter. Occasionally, during winter you might experience one week of cold weather. Not biting cold, but moderately uncomfortable weather. During this time, it's not unusual to see an over-reaction to the cold from the local populace. This over-reaction rears its head in the form of down jackets, gloves, scarves and beanies. 

Last year's winter was so moderate I don't even think I used a jacket, did I? Whereas in 2016 it got numbingly cold as the mercury dropped below five degrees Celsius. Most people will say that this year's summer was not as 'hot' as previous years, or cooler, which brings me to this winter, it definitely feels cooler. It could also just be that my apartment feels colder and indirectly, I feel colder.

I have been fundamentally opposed to buying a heater that will be used for one week of the year, only for it to end up in storage. Especially in a country where abundance of storage is non-existent. However, now that I am an official Hong Kong Resident I am entitled to my very own winter over-reaction, a heater. 

I'm too old to be cold.

The Silly Season

Towards the end of August, I found myself on a short hike out in Ham Tin. The day finished with seafood and wine in Sai Kung town. The following day, I woke up with a very achy sore right foot second toe; at the time I attributed the soreness to walking 45 minutes (yes, it was a short hike) in thongs. The soreness lasted a couple of months. Fast forward to Christmas Day and once again I've woken up with an incredibly sore foot. Specifically, where the big toe meets the ball the right foot. Different toe, same achy pain. Curious situation. I didn't kick a cinder block, or walk any substantial distance, I wasn't wearing new shows. Two separate instances that I've woken up with a sore toe, with no obvious moment of trauma.

So me, being me, I do three things. The first thing. I try to identify shared commonalities with the lead up to both events. One day of walking, one day without much walking. One day with lots of wine, one day with lots of wine. One day of outdoor activities, one day of socialising. One day with lots of cheese and seafood, one day with lots of seafood and purine-rich foods (think: liver and red meat). The second thing. With the help of the internet I jump to conclusions. The third thing. I go to my doctor and tell him that I think I have gout. He seems skeptical about this non-medical diagnosis based purely on my symptoms and my previously low uric acid levels appeared to suggest that gout did not seem likely. He then refers me to a foot specialist.

The Orthopaedic surgeon - she also doesn't think it's gout. Overarching medical consensus is that I would not be able to walk and that I would be experiencing more pain, even with acute gout. One thing that I've realised with my year of interaction with the medical system is that it's a lot of trail and error, attempting to diagnosis the symptoms with the aide of scans and test to come to a conclusion. We take an X-ray and find that there's no fracture, however there is a bit of bone that is floating right above the big toe. Which although unusual is unlikely to be the cause of my sore right toe. 

Here's the report:

The patient complained of right big toe pain and second toe pain for a few days. There was no history of injury. There was no family history of gout. The pain was exacerbated on walking. There was no rest pain. He also complained of left ankle instability symptoms. There was history of recurrent sprain for years. He last sprained his left ankle in mid Nov 2020.

On physical examination, there was minimal hallux valgus and bunionette deformity. There was no claw toe. There was mild callosity over the right second metatarsal head. There was a 5mm mobile roundish bony swelling at the right foot dorsum at subcutaneous plane. It was non tender on palpation and the Tinel sign was negative. 

For the left ankle, there was tenderness along the anteromedial joint line; there was also tenderness over the anterior talo-fibular ligament (ATFL) and the calcaneo-fibular ligament (CFL). The posterior talo-fibular ligament was non tender. Lateral laxity was grade 2.

X-ray right foot showed a bony loose body around the first metatarso-phalangeal joint, and minimal hallux valgus deformity.

So the soreness is likely to be caused by mild Hallux Valgus, or poor foot stability. However, in the space of 24 hours, I've gone from thinking that I have a uric acid problem, to finding I have a free floating piece of bone in my right foot, to having to get an MRI on my left ankle. It really is the silly season.

Boxing Day

It's a weird feeling being grounded in one place for such a long time. Living in Europe and Asia has provided the ability to travel with very little planning, thought and even gratitude to having access to so many destinations; It's something that I had definitely taken for granted. As we draw towards the end of the year it is kind of nice to have everybody in town. Christmas and New Years in Hong Kong always feels like a partial affair, most of the group are away traveling, visiting family back home or just making the most of the winter holidays.

I like to think that this year's Boxing Day is an ode to previous Boxing Day's in Sydney. Me on the sofa, with little appetite from the Christmas Eve and Christmas day over eating. I'm watching the Boxing Day Cricket test, eating Tim Tams and Minties, while navigating the "virtual" Boxing Day sales with some online shopping.

Pranayama and Meditation

The Anahata Pranayama and Meditation course is held twice a year. The pace is noticeably slower compared to the foundational course that I attended earlier this year. The emphasis less on Asanas (poses) and (not surprisingly) more on Pranayama (breathing) and Meditation. There are 16 students enrolled in the December class which suggests that there is less interest in the topic compared to the Asanas, or potentially the effect of Covid. The start of the course coincided with the fourth wave in Hong Kong, and aside from two classes that were held in the studio, all the classwork was done online.

There is some overlap with the chakras, kriyas and bandhas but majority of the content was new. I particularly enjoyed the breath work content. Once again, there is a practical component, which requires the student to walk the class through a meditation technique as well as a pranayama technique. Three teachers, Anurag, Dhiraj as well as Yogananth guiding us through the practise. 

15,500 HKD (~2,000 USD) - lucked out as work paid for the course