Continuing Education Activity

This continuing medical education (CME) activity explores the clinical application of mindfulness-based stress reduction (MBSR) as a valuable adjunct to standard care interventions. Developed by psychotherapy pioneer Jon Kabat-Zinn, MBSR offers a self-regulated state of non-judgmental and purposeful awareness, which has proven effective in managing chronic pain, stress, anxiety, and depression. The course delves into the evidence supporting MBSR's positive impact on patient outcomes and quality of life, emphasizing its potential to reduce reliance on pharmaceutical interventions with potential adverse effects. Participants will gain insights into the components and techniques of MBSR, understanding how it encourages patient autonomy and complements conventional treatments. Moreover, the session explores the neuroscience behind mindfulness, highlighting its role in strengthening neuronal networks, improving emotional regulation, and enhancing adaptive stress responses. This CME activity empowers healthcare professionals with the knowledge and skills to integrate MBSR seamlessly into their clinical practice, promoting holistic patient care.

In addition to exploring MBSR's clinical applications, this CME activity provides a comprehensive overview of the nature of stress. Stress, a fundamental aspect of life, is examined in its positive and negative manifestations. The course reviews the physiological underpinnings of stress, focusing on the role of the hypothalamic-pituitary-adrenal (HPA) axis in regulating the stress response. Participants will gain insights into the intricate balance of cortisol, the stress hormone, and its effects on alertness, focus, and energy. The session emphasizes the importance of managing excessive stress to maintain a healthy lifestyle, addressing the potential detrimental effects of prolonged stress on sleep patterns, cognitive function, and overall health. Participants will explore the evidence supporting non-pharmacological behavioral interventions like MBSR in regulating the HPA axis, focusing on breathing exercises, meditation, and mindfulness. This CME activity provides clinicians with a comprehensive understanding of stress physiology and practical tools to incorporate mindfulness into patient care for effective stress management.

Objectives:

• Apply components of mindfulness-based stress reduction to manageable elements of the stress response.
• Determine how mindfulness-based stress reduction (MBSR) skills can help patients intervene in stress reactions and better care for themselves.
• Compare integral and essential elements of MBSR and interpret conclusions from salient research in MBSR.
• Identify mindfulness skills that enable presence, clarity, and curiosity in the clinical encounter.

Introduction

Mindfulness is a self-regulated state of non-judgemental and purposeful awareness of the present moment.[1] Psychotherapy pioneer Jon Kabat-Zinn developed the mindfulness-based stress reduction (MBSR) protocol for the self-regulation of chronic pain and stress through meditation and mindfulness.[2] In preliminary studies, Kabat-Zinn describes how meditation facilitates a state of detached observation by redirecting attention toward proprioception.[2] This "uncouples" the sensory component of pain from the affective or emotional element, thus reducing suffering through cognitive reappraisal.[2] Individuals can reinterpret and reframe their thoughts through cognitive reappraisal, reducing stress and suffering. Studies report strong adherence and long-term positive effects of MBSR on stress, depression, anxiety, and pain following the training period, with benefits lasting for several years.[3][2] A pivotal study on mindfulness and the brain demonstrated that a brief MBSR program increased left-sided anterior activity correlated with positive affect.[4] 

More recent research further supports this finding, indicating that mindfulness meditation reduces stress and enhances the activation of brain regions linked to mood regulation and attention control.[5] Specifically, it is suggested that MBSR improves the activation of the brain's anterior cingulate cortex, an executive attention center.[5] These findings highlight how mindfulness strengthens neuronal networks, cultivating self-awareness, emotional regulation, and adaptive stress responses.[5] Furthermore, mindfulness may strengthen the mind-body connection, enabling individuals to effectively self-regulate symptoms of pain, anxiety, depression, and stress.[6] Mindfulness aims to liberate the self from physical and psychological suffering while cultivating the necessary skills to manage stressful situations.[7] It is emphasized that mindfulness is not a quick fix but a long-term intervention that requires dedicated practice and an intentional way of living.

Nature of Stress

Stress is a fundamental and necessary part of life. Stress is not exclusive to negative experiences and may result from any form of stimulation, including positive experiences.[8] Cortisol, the stress hormone, is produced during negative and positive experiences and is crucial in promoting alertness, focus, and energy. It allows us to get up in the morning and maintain energy throughout the day. However, prolonged or excessive stress can have detrimental effects on our health. High cortisol levels over an extended period can disrupt sleep patterns, impair cognitive function, weaken the immune system, and contribute to various health problems.[9] Therefore, while stress is essential in moderate amounts, it is crucial to manage excessive stress to maintain a healthy lifestyle. The body's response to stressors can be observed through physiological and behavioral changes controlled by biological processes.[9]

Recent research supports the theory that the hypothalamic-pituitary-adrenal (HPA) axis regulates the stress response.[9] Activation of the HPA axis begins through an initial exposure to a stressor. The activation of the HPA axis has neuronal origins regulated by the paraventricular nucleus of the hippocampus, which releases corticotropin-releasing factors.[10] The HPA axis then releases glucocorticoids, stimulating the body's physical response to stress.[10] 

Glucocorticoids and other cortical hormones are major regulators of the HPA axis and normally produce a healthy, adaptive stress response. However, chronic stress results in excessive or prolonged activation of the HPA axis, leading to dysregulation and a maladaptive stress response.[10] A wide body of evidence supports using a mind-body approach to regulate the HPA axis and address psychophysiological stress.[11][12][13] Non-pharmacological behavioral interventions like MBSR have been shown to effectively regulate exaggerated or problematic stress responses through breathing exercises, meditation, and mindfulness (see Image. MSBR and Stress).[6] Behavioral interventions like MBSR aim not to remove stress but to manage it effectively and completely. 

Function

MBSR Protocol 

Jon Kabat-Zinn developed the Mindfulness-Based Stress Reduction protocol in the 1980s.[2] The MBSR protocol is implemented over 8 consecutive weeks, improving awareness of health and reducing stress. The program requires that participants attend a weekly, 2-hour group class that teaches non-religious meditation-based behavioral techniques to manage stress.[2][7] The meditation-based techniques include Hatha Yoga, breathing exercises, sitting meditations, and "body scans." The protocol assigns homework through yoga and meditation sessions lasting 45 minutes daily, 6 days a week. Participants supplement the meditation and yoga study with guided audio recordings. Using a workbook, participants must also engage in awareness exercises for 15 minutes daily. On the 6th week of the program, participants attend an 8-hour-long retreat. The goal of practicing mindfulness-based techniques daily is to establish their efficacy as a sustainable, lifelong intervention.

Body Scanning 

An essential meditation technique used in MBSR is the "body scan." This meditation is performed lying down and involves energetically "sweeping" the body with the mind.[14] The guided body scan directs the meditator to visualize a "compassionate awareness" starting at the tip of their toes that slowly progresses from their feet, going up their legs, passing through their pelvic region, hips, buttocks, abdomen, ribs, chest, lungs, shoulder blades, fingers, and arms, then back up to the shoulders and through the neck, throat, face, and head.[14] Along the way, the guide will instruct the meditator to recognize certain anatomical areas like the heart, throat, or pelvic region, which may hold particularly emotional or strong memories.[14] 

The body scan meditation can also be self-guided. This allows the meditator to spend more time scanning certain areas of the body, which may hold the personal significance of past experiences and emotions, before moving on to the next region. The MBSR protocol includes 45 minutes of daily body scan meditation and breathing exercises. The benefits of body scan meditation have been studied in research. A recent functional magnetic resonance imaging (fMRI) study found that body scan meditation increases interoceptive awareness by enhancing the connection between the salience network and frontal/central gyri.[15] The same study found that the body scan improved emotional regulation, which persisted after the MBSR intervention.[15] 

Hatha Yoga 

A critical component of MBSR is Hatha yoga. Like other forms of yoga, Hatha yoga integrates a series of physical poses and structured movements known as "asanas" with breathing exercises known as "pranayamas."[16] A popular breathwork technique used in Hatha yoga is diaphragmatic breathing. This breathing technique involves a deep and prolonged inhalation, a period of breath retention, and a slow, controlled exhalation.[16] Diaphragmatic breathing has been proven to reduce cortisol levels produced by the HPA axis during the stress response.[17] Research on Hatha yoga reports improved attention, concentration, psychological distress, and sleep quality.[18][19] These findings highlight the critical role of Hatha yoga in MBSR.

Issues of Concern

Anxiety MBSR 

Pharmacotherapy has usually been the first-line treatment for anxiety. However, psychotherapy programs such as mindfulness-based stress reduction are especially effective for individuals suffering from mental health conditions like anxiety.[20][6] Treatment using MBSR therapy is performed similarly to escitalopram, a popular anxiety medication.[20] Through MBSR training, individuals with generalized anxiety disorder experienced decreased inflammatory cytokines and a decrease in HPA axis effectors like adrenocorticotropic hormone.[13] Mindfulness-based stress reduction training was reported to be more effective than general stress management education at improving generalized anxiety disorder.[13] 

The successful regulation of the HPA axis can reduce cortisol levels, improving symptoms of stress and anxiety.[21] One study utilized fMRI to demonstrate the neural effects of MBSR training on individuals with social anxiety disorder.[22] The training resulted in (1) an increase in neural network activity in areas of the brain associated with attention regulation, (2) a reduction in neural activity in the parts of the brain associated with conceptual self-view, and (3) a decrease in reported anxiety.[22]

Depression MBSR 

MBSR is a promising and increasingly popular treatment option for depression. An increasing number of patients prefer psychotherapy over pharmacotherapy to treat depression.[23] Clinicians must honor patient preference as it strongly predicts successful outcomes.[23] Furthermore, several meta-analyses report that mindfulness-based interventions significantly improved depressive symptoms and provided comparable outcomes to standard care interventions.[24][25] Several studies found that MBSR training significantly reduced depression in healthy individuals and those suffering from chronic illnesses like cancer.[26][27][28] 

Similar to other forms of psychotherapy, there is concern that moderating variables like spirituality, religiosity, or age sway the benefits of MBSR. A recent study examined the most common moderating variables and proved that an MBSR treatment program improved depressive symptoms across all groups, regardless of trait mindfulness, age, spirituality, or religiosity.[29] Psychotherapy like MBSR can be used alone or in combination with other interventions like pharmacotherapy to address the unique needs of every individual patient.[30]

Stress MBSR

Stress is detrimental to health and results in adverse physical and psychological consequences. One study examined the effect of MBSR on healthy individuals and found that participation in an MBSR program reduced symptoms of stress while enhancing mindfulness and self-compassion.[31] Meta-analyses describe similar results among healthy individuals, including increased self-compassion, reduction of stress symptoms, and even a reduction in symptoms of anxiety and reflective thinking.[32][28] 

Generally, MBSR may provide nonspecific benefits for health and wellness. However, MBSR may also be a specific intervention for chronic illness and other stress-inducing states. Studies have examined the effect of MBSR training on cancer patients and reported reductions in stress-induced cardiopulmonary and gastrointestinal symptoms, emotional irritability, mood disturbances, and even a 31% decrease in overall stress.[27][26] Additional research demonstrates that the training reduced perceived medical symptoms, including pain, in populations suffering from chronic illnesses.[33][34] In addition, MBSR produced a sustainable reduction in symptoms of stress and anxiety in individuals working high-demand jobs, including healthcare and teaching.[35][36] 

Pain 

The consequences of the opioid epidemic popularized MBSR as an alternative or complement to pharmaceutical use.[37] Long-term use of opioids is correlated with a lack of therapeutic efficacy, addiction, and hyperalgesia, highlighting the need for treatment alternatives.[38] Approximately two-thirds (65%) of the patients in a preliminary study on MBSR experienced a ≥33% reduction in pain in the following categories: back, facial, neck, headache, shoulder, noncoronary chest pain, and GI pain.[39][2] Additionally, some participants experienced a statistically significant reduction in physical pain and mood disturbances.[39][2] Further research on MBSR and chronic pain demonstrates significant reductions in medication reliance and present-moment pain, with some patients reporting reduced medication use by the study's end.[7]

A more recent study further supports these findings, showing a 30% improvement in long-term clinical symptoms of lower back pain.[40] Recent research on lower back pain found that MBSR produced more clinically meaningful pain improvement than usual care interventions.[41] The benefits of MBSR extend to patients with chronic headaches, fibromyalgia, and general bodily pain, significantly reducing perceived pain severity across pain types.[42] MBSR can complement standard care by providing a multimodal treatment approach for individuals with chronic conditions like fibromyalgia. Several studies have shown that integrating MBSR with usual care significantly reduces chronic pain and improves the quality of life for fibromyalgia patients.[2][43] Non-pharmacological pain treatments offer extensive benefits beyond pain relief, enhancing their overall quality of life and functional capacity. As a result, psychotherapy is recommended as the first-line treatment for chronic pain.[37] 

Clinical Significance

Healthcare Delivery 

Provider mindfulness has been proposed for integration into regular medical practice. Mindfulness teaches presence, self-reflection, and non-judgment and may enhance clinician decision-making and technical competence.[44] Present-moment awareness allows providers to engage with the patient fully and to be free from preoccupations. This “presence” facilitates accurate assessment, diagnosis, and treatment planning while fostering a patient-centered environment. Self-reflection encourages clinicians to recognize errors and refine clinical skills.[44] A mindful clinician may suspend preconceived biases and allow curiosity and compassion to lead their care. Conversely, mindlessness may result in technical errors like anchoring bias, judgment errors, and attribution errors (stereotyping).[44][1] A recent study involving healthcare workers found that an MBSR program increased feelings of common humanity, self-compassion, and awareness while reducing reactivity and judgment.[45] The valuable contribution of MBSR to healthcare delivery is evident and warrants greater utilization.

Clinical Application 

The acceptability and accessibility of mindfulness-based interventions is the greatest barrier to patient utilization. Patients may believe pain medication is the only approach to treating chronic pain, disregarding the potential effectiveness of non-pharmacological interventions. Providers can address the issue of acceptability by educating patients about the biological process of pain regulation and highlighting compelling evidence that supports mindfulness interventions. Clinicians can support their recommendations with the following evidence: (1) pain regulation involves top-down processing which is not fully engaged during pharmacotherapy, (2) meditation engages central brain networks that are involved in pain regulation, (3) pain medication carries the risk of dependency and can induce hyperalgesia, a condition characterized by increased sensitivity to pain, (4) mindfulness interventions reduce pain in the long term and help maintain functional capacity, (5) MBSR has been shown to decrease levels of inflammatory cytokines, and stress hormones ACTH and cortisol.[37][13] 

Furthermore, the lack of clarity surrounding the accessibility of mindfulness-based interventions often discourages patients from seeking them out. Clinicians should guide patients to online and telephone-based programs or refer them to individual or group therapy sessions at local mindfulness centers. It is essential to discuss self-implementation strategies to address personal barriers and to empower patients to participate in the treatment process. Providers can enhance their treatment approaches by incorporating MBSR as a complementary intervention. The clinical application and efficacy of MBSR may open the door to a transformative approach to how medicine addresses chronic conditions.

Enhancing Healthcare Team Outcomes

Pain and Psychological Conditions 

Stress, pain, depression, and anxiety are conditions that can significantly impact an individual's well-being and overall quality of life. These conditions may coexist and exacerbate each other, leading to a complex and challenging clinical presentation. Mindfulness-based stress reduction (MBSR) is a valuable intervention for individuals struggling with pain, depression, stress, and anxiety. MBSR combines meditation, yoga, and other contemplative practices to cultivate a non-judgmental awareness of the present moment. By incorporating mindfulness into their daily lives, individuals can develop skills to manage pain better, regulate emotions, and manage stressful situations.

Evidence-based Approach 

The interprofessional team plays a crucial role in the evaluation and treatment of individuals with pain, stress, depression, and anxiety. Collaborating professionals, including physicians, psychologists, psychiatrists, and therapists, work together to assess and comprehensively address the multifaceted aspects of these conditions. Through shared decision-making and effective communication, the interprofessional team tailors personalized treatment plans that may include a combination of pharmacological interventions, psychotherapy, mindfulness-based interventions like MBSR, and other complementary approaches. MBSR therapy is an evidence-based approach in the Lifestyle Medicine Board Review Manual.[46] 

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008 Sep 17;300(11):1350-2. [PubMed: 18799450]

2.

Kabat-Zinn J, Chapman-Waldrop A. Compliance with an outpatient stress reduction program: rates and predictors of program completion. J Behav Med. 1988 Aug;11(4):333-52. [PubMed: 3070046]

3.

Santamaría-Peláez M, González-Bernal JJ, Verdes-Montenegro-Atalaya JC, Pérula-de Torres LÁ, Roldán-Villalobos A, Romero-Rodríguez E, Hachem Salas N, Magallón Botaya R, González-Navarro TJ, Arias-Vega R, Valverde FJ, Jiménez-Barrios M, Mínguez LA, León-Del-Barco B, Soto-Cámara R, González-Santos J. Mindfulness-Based Program for Anxiety and Depression Treatment in Healthcare Professionals: A Pilot Randomized Controlled Trial. J Clin Med. 2021 Dec 17;10(24) [PMC free article: PMC8708843] [PubMed: 34945237]

4.

Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Urbanowski F, Harrington A, Bonus K, Sheridan JF. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003 Jul-Aug;65(4):564-70. [PubMed: 12883106]

5.

Tang YY, Hölzel BK, Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015 Apr;16(4):213-25. [PubMed: 25783612]

6.

Hofmann SG, Gómez AF. Mindfulness-Based Interventions for Anxiety and Depression. Psychiatr Clin North Am. 2017 Dec;40(4):739-749. [PMC free article: PMC5679245] [PubMed: 29080597]

7.

Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985 Jun;8(2):163-90. [PubMed: 3897551]

8.

Lu S, Wei F, Li G. The evolution of the concept of stress and the framework of the stress system. Cell Stress. 2021 Apr 26;5(6):76-85. [PMC free article: PMC8166217] [PubMed: 34124582]

9.

Ulrich-Lai YM, Herman JP. Neural regulation of endocrine and autonomic stress responses. Nat Rev Neurosci. 2009 Jun;10(6):397-409. [PMC free article: PMC4240627] [PubMed: 19469025]

10.

Smith SM, Vale WW. The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress. Dialogues Clin Neurosci. 2006;8(4):383-95. [PMC free article: PMC3181830] [PubMed: 17290797]

11.

Manigault AW, Shorey RC, Hamilton K, Scanlin MC, Woody A, Figueroa WS, France CR, Zoccola PM. Cognitive behavioral therapy, mindfulness, and cortisol habituation: A randomized controlled trial. Psychoneuroendocrinology. 2019 Jun;104:276-285. [PubMed: 30917336]

12.

Puhlmann LMC, Vrtička P, Linz R, Stalder T, Kirschbaum C, Engert V, Singer T. Contemplative Mental Training Reduces Hair Glucocorticoid Levels in a Randomized Clinical Trial. Psychosom Med. 2021 Oct 01;83(8):894-905. [PMC free article: PMC8505163] [PubMed: 34259441]

13.

Hoge EA, Bui E, Palitz SA, Schwarz NR, Owens ME, Johnston JM, Pollack MH, Simon NM. The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Res. 2018 Apr;262:328-332. [PMC free article: PMC5526744] [PubMed: 28131433]

14.

Roll SC, Hardison ME, Vigen C, Black DS. Mindful Body Scans and Sonographic Biofeedback as Preparatory Activities to Address Patient Psychological States in Hand Therapy: A Pilot Study. Hand Ther. 2020 Sep;25(3):98-106. [PMC free article: PMC7685254] [PubMed: 33244321]

15.

Guu SF, Chao YP, Huang FY, Cheng YT, Ng HH, Hsu CF, Chuang CH, Huang CM, Wu CW. Interoceptive awareness: MBSR training alters information processing of salience network. Front Behav Neurosci. 2023;17:1008086. [PMC free article: PMC10070746] [PubMed: 37025109]

16.

Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase quality of life. Int J Yoga. 2011 Jul;4(2):49-54. [PMC free article: PMC3193654] [PubMed: 22022122]

17.

Ma X, Yue ZQ, Gong ZQ, Zhang H, Duan NY, Shi YT, Wei GX, Li YF. The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Front Psychol. 2017;8:874. [PMC free article: PMC5455070] [PubMed: 28626434]

18.

Baklouti S, Aloui A, Baklouti H, Souissi N, Jarraya M. Effects of Hatha yoga on cognitive functions in the elderly: a cross-sectional study. Libyan J Med. 2022 Dec;17(1):2080799. [PMC free article: PMC9176371] [PubMed: 35657065]

19.

Baklouti S, Fekih-Romdhane F, Guelmami N, Bonsaksen T, Baklouti H, Aloui A, Masmoudi L, Souissi N, Jarraya M. The effect of web-based Hatha yoga on psychological distress and sleep quality in older adults: A randomized controlled trial. Complement Ther Clin Pract. 2023 Feb;50:101715. [PMC free article: PMC9744484] [PubMed: 36521407]

20.

Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. 2023 Jan 01;80(1):13-21. [PMC free article: PMC9647561] [PubMed: 36350591]

21.

Lenze EJ, Mantella RC, Shi P, Goate AM, Nowotny P, Butters MA, Andreescu C, Thompson PA, Rollman BL. Elevated cortisol in older adults with generalized anxiety disorder is reduced by treatment: a placebo-controlled evaluation of escitalopram. Am J Geriatr Psychiatry. 2011 May;19(5):482-90. [PMC free article: PMC3424606] [PubMed: 20808146]

22.

Goldin P, Ramel W, Gross J. Mindfulness Meditation Training and Self-Referential Processing in Social Anxiety Disorder: Behavioral and Neural Effects. J Cogn Psychother. 2009 Aug;23(3):242-257. [PMC free article: PMC4283801] [PubMed: 25568592]

23.

Winter SE, Barber JP. Should treatment for depression be based more on patient preference? Patient Prefer Adherence. 2013;7:1047-57. [PMC free article: PMC3797653] [PubMed: 24143080]

24.

Klainin-Yobas P, Cho MA, Creedy D. Efficacy of mindfulness-based interventions on depressive symptoms among people with mental disorders: a meta-analysis. Int J Nurs Stud. 2012 Jan;49(1):109-21. [PubMed: 21963234]

25.

Kuyken W, Byford S, Taylor RS, Watkins E, Holden E, White K, Barrett B, Byng R, Evans A, Mullan E, Teasdale JD. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psychol. 2008 Dec;76(6):966-78. [PubMed: 19045965]

26.

Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med. 2000 Sep-Oct;62(5):613-22. [PubMed: 11020090]

27.

Garland SN, Carlson LE, Cook S, Lansdell L, Speca M. A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. Support Care Cancer. 2007 Aug;15(8):949-61. [PubMed: 17611782]

28.

Sharma M, Rush SE. Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a systematic review. J Evid Based Complementary Altern Med. 2014 Oct;19(4):271-86. [PubMed: 25053754]

29.

Greeson JM, Smoski MJ, Suarez EC, Brantley JG, Ekblad AG, Lynch TR, Wolever RQ. Decreased symptoms of depression after mindfulness-based stress reduction: potential moderating effects of religiosity, spirituality, trait mindfulness, sex, and age. J Altern Complement Med. 2015 Mar;21(3):166-74. [PMC free article: PMC4365440] [PubMed: 25695903]

30.

Cuijpers P, van Straten A, Hollon SD, Andersson G. The contribution of active medication to combined treatments of psychotherapy and pharmacotherapy for adult depression: a meta-analysis. Acta Psychiatr Scand. 2010 Jun;121(6):415-23. [PubMed: 19922522]

31.

Bergen-Cico D, Possemato K, Cheon S. Examining the efficacy of a brief mindfulness-based stress reduction (Brief MBSR) program on psychological health. J Am Coll Health. 2013;61(6):348-60. [PubMed: 23930749]

32.

Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. J Altern Complement Med. 2009 May;15(5):593-600. [PubMed: 19432513]

33.

Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008 Feb;31(1):23-33. [PubMed: 17899351]

34.

Carmody J, Reed G, Kristeller J, Merriam P. Mindfulness, spirituality, and health-related symptoms. J Psychosom Res. 2008 Apr;64(4):393-403. [PubMed: 18374738]

35.

Martín-Asuero A, García-Banda G. The Mindfulness-based Stress Reduction program (MBSR) reduces stress-related psychological distress in healthcare professionals. Span J Psychol. 2010 Nov;13(2):897-905. [PubMed: 20977037]

36.

Flook L, Goldberg SB, Pinger L, Bonus K, Davidson RJ. Mindfulness for teachers: A pilot study to assess effects on stress, burnout and teaching efficacy. Mind Brain Educ. 2013 Sep;7(3) [PMC free article: PMC3855679] [PubMed: 24324528]

37.

Morone NE. Not Just Mind Over Matter: Reviewing With Patients How Mindfulness Relieves Chronic Low Back Pain. J Evid Based Integr Med. 2019 Jan-Dec;24:2515690X19838490. [PMC free article: PMC6448108] [PubMed: 30942087]

38.

Zgierska AE, Burzinski CA, Cox J, Kloke J, Stegner A, Cook DB, Singles J, Mirgain S, Coe CL, Bačkonja M. Mindfulness Meditation and Cognitive Behavioral Therapy Intervention Reduces Pain Severity and Sensitivity in Opioid-Treated Chronic Low Back Pain: Pilot Findings from a Randomized Controlled Trial. Pain Med. 2016 Oct;17(10):1865-1881. [PMC free article: PMC5063022] [PubMed: 26968850]

39.

Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47. [PubMed: 7042457]

40.

Morone NE, Greco CM, Moore CG, Rollman BL, Lane B, Morrow LA, Glynn NW, Weiner DK. A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Intern Med. 2016 Mar;176(3):329-37. [PMC free article: PMC6361386] [PubMed: 26903081]

41.

Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2016 Mar 22-29;315(12):1240-9. [PMC free article: PMC4914381] [PubMed: 27002445]

42.

Marske C, Shah S, Chavira A, Hedberg C, Fullmer R, Clark CJ, Pipitone O, Kaiser P. Mindfulness-Based Stress Reduction in the Management of Chronic Pain and Its Comorbid Depression. J Am Osteopath Assoc. 2020 Sep 01;120(9):575-581. [PubMed: 32854117]

43.

Grossman P, Tiefenthaler-Gilmer U, Raysz A, Kesper U. Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up benefits in well-being. Psychother Psychosom. 2007;76(4):226-33. [PubMed: 17570961]

44.

Epstein RM. Mindful practice. JAMA. 1999 Sep 01;282(9):833-9. [PubMed: 10478689]

45.

Zimmaro LA, Moss A, Reibel DK, Handorf EA, Reese JB, Fang CY. A Telephone-Adapted Mindfulness-Based Stress Reduction Program: Preliminary Effects among Healthcare Employees. Behav Sci (Basel). 2021 Oct 18;11(10) [PMC free article: PMC8533574] [PubMed: 34677232]

46.

Shurney D. Employing Mindfulness in Lifestyle Medicine. Am J Lifestyle Med. 2019 Nov-Dec;13(6):561-564. [PMC free article: PMC6796219] [PubMed: 31662722]

Disclosure: Ranya Srour declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Keyes declares no relevant financial relationships with ineligible companies.