Evidence Map of Mindfulness

Many Veterans desire complementary and alternative medicine or integrative medicine modalities, both for treatment and for the promotion of wellness. Given VA's desire to promote evidence-based practice, this evidence mapping project aims to help provide guidance to VA leadership about the distribution of evidence on mindfulness approaches. Mindfulness, often translated from Sanskrit to mean "awareness," is an ancient Buddhist concept and, although many different forms and definitions exist, a central aspect of the practice is the intention to be more aware and engaged in the present moment. Kabat-Zinn is often credited with popularizing mindfulness in the U.S. by creating a mindfulness-based stress reduction (MBSR) program for treating chronic disease, which created institutional capacity for using mindfulness-approaches in clinical settings.

The VA Evidence-Based Synthesis Program located in West Los Angeles, CA conducted a systematic review of 10 electronic databases through February 2014 to examine the evidence on the effectiveness of mindfulness interventions. After applying inclusion/exclusion criteria, they identified 81 unique systematic reviews on mindfulness interventions that were used to provide the following Summary and bubble plot.

Summary:
Most research is available for general overviews on health benefits or psychological wellbeing. Reviews on chronic illness, depression, substance use, somatization, distress, and mental illness also included 10 or more randomized controlled trials (RCTs). The largest review included 109 mindfulness RCTs. Reviews suggest differential effects of mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and other mindfulness-based interventions, and definitions of "mindfulness-based" varied. The most consistent beneficial effect for various mindfulness interventions was reported for depression. Published meta-analyses of MBSR also indicated beneficial effects compared to passive control (e.g., no intervention) on overall health and psychological outcomes and for chronic illness. In addition, reviews indicated positive effects of Mindfulness-based Cognitive Therapy (MBCT) for mental illness and of various mindfulness interventions for somatization disorders. All depicted dimensions are estimates and can only provide a broad overview of the evidence base.

Bubble Plot:
The following bubble plot broadly summarizes mindfulness intervention systematic reviews published up to February 2014 – and shows the clinical conditions addressed in reviews (bubbles), the estimated size of the literature based on number of RCTs in the largest review (y-axis), the effectiveness trend according to reviews (x-axis), and the number of reviews (bubble size) per clinical condition. Colors: green (various mindfulness interventions), pink (MBSR), purple (MBCT), blue (MBSR+MBCT), and yellow (unique mindfulness-based intervention).

Future Research:
Investigators specifically searched systematic reviews for research on patients' experiences, sleep disturbance, hot flashes, eating disorders, and intellectual disability for mindfulness intervention studies, but no RCTs (i.e., high level of evidence research studies) were identified. Most evidence is available for comparisons of mindfulness interventions and passive comparators, but information on comparisons to active control groups and comparative effectiveness research is currently very limited. The evidence map has identified a number of areas with unclear evidence. Future systematic reviews may provide more definitive answers. In some cases, the scope of the review might have to be reduced to concentrate on specific outcomes or clinical indications, and the effect of MBSR, MBCT, and other mindfulness-based interventions may need to be evaluated individually.

A protocol for a Cochrane review on mindfulness-based 'third wave' cognitive and behavioral therapies (including MBCT, Acceptance and Commitment Therapy, Compassionate Mind Training, and Dialectical Behavior Therapy) for depression has been published in 2010 and was updated in 2012. Unpublished systematic reviews registered in PROSPERO address MBSR in breast cancer care, mindfulness-based approaches to treat pathological gambling, mindfulness meditation for overeating and weight loss, mindfulness in primary care, and MBCT and MBSR for depression and vascular disease.

Reference:
Hempel, S, Taylor, SL, Marshall, NJ, Miake-Lye, IM, Beroes, J M, Shanman, R, Solloway, MR, Shekelle, PG. Evidence Map of Mindfulness. VA-ESP Project #05-226; 2014.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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