p02-10. medn for ramesh · 2020. 3. 2. · sense of control over the events and symptoms in one’s...

Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2011, Article ID 960583, 8 pagesdoi:10.1155/2011/960583

Research Article

A Randomized, Controlled Trial of Meditation for Work Stress,Anxiety and Depressed Mood in Full-Time Workers

R. Manocha,1 D. Black,2 J. Sarris,3, 4 and C. Stough4

1 Discipline of Psychiatry, Sydney Medical School, Royal North Shore Hospital, Sydney University, St Leonards, NSW 2065, Australia2 Faculty of Health Sciences, Cumberland Campus C42, The University of Sydney, P.O. Box 170, Lidcombe, NSW 1825, Australia3 Department of Psychiatry, The University of Melbourne, Melbourne, VIC 3121, Australia4 NICM Collaborative Centre for Neurocognition, Swinburne University of Technology, Melbourne, Australia

Correspondence should be addressed to R. Manocha, [email protected]

Received 9 February 2011; Revised 4 March 2011; Accepted 9 March 2011

Copyright © 2011 R. Manocha et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. To assess the effect of meditation on work stress, anxiety and mood in full-time workers. Methods. 178 adult workersparticipated in an 8-week, 3-arm randomized controlled trial comparing a “mental silence” approach to meditation (n = 59) to a“relaxation” active control (n = 56) and a wait-list control (n = 63). Participants were assessed before and after using PsychologicalStrain Questionnaire (PSQ), a subscale of the larger Occupational Stress Inventory (OSI), the State component of the State/TraitAnxiety Inventory for Adults (STAI), and the depression-dejection (DD) subscale of the Profile of Mood States (POMS). Results.There was a significant improvement for the meditation group compared to both the relaxation control and the wait-list groupsthe PSQ (P = .026), and DD (P = .019). Conclusions. Mental silence-orientated meditation, in this case Sahaja Yoga meditation, isa safe and effective strategy for dealing with work stress and depressive feelings. The findings suggest that “thought reduction” or“mental silence” may have specific effects relevant to work stress and hence occupational health.

1. Introduction

Health professionals, consumers, and patients are becomingincreasingly enthusiastic about meditation; a survey of Aus-tralian GPs in 2000 found that almost 80% of respondentshad recommended meditation to patients at some time inthe course of their practice [1]. A nationally representativesurvey of US households in 1998 indicated that almost1 in 5 consumers had used some form of “mind-bodytherapy” in the past 12 months, of which meditation was thecommonest method [2]. While a survey of cancer sufferersin the UK found that meditative practices were the mostpopular complementary therapy used by this patient group[3].

The vast majority of research into meditation is focusedon stress-related issues and indeed much of the enthu-siasm amongst both health professionals and the generalcommunity is derived from these reports. Is meditationeffective in reducing occupational stress, and if it is, is itmore effective than placebo? Do different approaches tomeditation have different effects? Canter explained that themajority of meditation research is characterized by poor

methodological quality such that it was not yet possible todetermine whether or not meditation is associated with aspecific effect beyond that of placebo or simple rest [4].Probably the most thorough and up to date review ofmeditation research was published in 2007 by a team ledby Ospina, specifically contracted by the US Department ofHealth and Human Services to assess the evidence base [5].They included both randomized and nonrandomized trials.In their assessment of more than 800 studies, they concluded

“Many uncertainties surround the practice ofmeditation. Scientific research on meditationpractices does not appear to have a commontheoretical perspective and is characterized bypoor methodological quality. Firm conclusionson the effects of meditation in healthcare cannotbe drawn based on the available evidence.”

A handful of key methodological and conceptual prob-lems were identified that, if addressed, would significantlyadvance our understanding about meditation’s potential rolein clinical practice. Two problems of particular importanceare, first, the need for strategies to control for nonspecific

2 Evidence-Based Complementary and Alternative Medicine

Drop out

N = 17

Mental silence

meditation (SYM)

N = 59

Completed

interventionN = 40

Drop out

N = 16

Relaxation

meditation (RM)

N = 56

Completed

interventionN = 39

Drop out

N = 24

Waiting

list (WL)

N = 63

Randomised in treatment group

phone notification of allocationN = 178

Randomised in treatment groupunable to participate further

N = 2

Attended briefing sessionsigned consent form

baseline questionnaire

N = 180

Completed

interventionN = 42

Attended briefing sessiondid not sign consent formdid not parti ic pate further

N = 70

Phone screening

for eligibility

N = 250

8-week 8-week 8-week

Figure 1: Consort diagram for work stress study.

effects associated with any meditation-like intervention and,second, greater clarity in defining meditation.

Stress is currently understood in terms of an individual’ssense of control over the events and symptoms in one’slife [6]. When individuals believe that they can controlnegative events, they cope better and experience less stress.It is commonly defined as “a particular relationship betweenthe person and environment that is appraised by theperson as taxing or exceeding his or her resources andendangering his other wellbeing” [7]. Stress is associatedwith physiological hyperarousal, negative cognitions, andnegative mood and has been associated with a wide varietyof physical and mental health problems. The relationshipbetween psychosocial stress and cardiovascular disease, forexample, is becoming increasingly significant to clinicians[8, 9]. A 2006 insurance survey reported that seven millionBritons experiencing stress related symptoms sufficient tocompel them to seek medical attention [10]. Studies estimatethat 50–70% of general practice consultations feature stress-related issues [11]. The Bristol Stress and Health Studyassessed 17,000 workers and found that approximately 20%of respondents experienced very high or extremely highlevels of stress at work and that this stress was associated withnegative effects on physiology, mental performance, and riskof work place accidents [12].

Individually orientated interventions for stress suchas meditation are simple yet potentially effective healthpromotional strategies [13]. As a result, they are becomingincreasingly popular within organizations [14]; however,these interventions have to date not been rigorously evalu-ated. In fact, only a small number of RCTs of meditation

for work stress have been reported in the literature [15–22] and none so far provide convincing evidence for aspecific effect. Meditation is commonly thought to reducestress by a combination of two pathways. First, by reducingsomatic-arousal (physiological effects) [23] thereby reducingreactivity of the individual to environmental stressors, andsecond, by altering the individual’s cognitive appraisal ofand perceived self-efficacy with regard to stressors [24].The cognitive-behavioral effects are thought to result fromthe meditator’s increased awareness of how thoughts andemotions arise in response to various environmental events,thereby allowing the meditator to achieve more veridicalperception, reduced negative affect, and improved vitalityand coping [25].

The RCT reported here was thus designed to addresstwo interconnected questions: first, and primarily, whetheror not meditation is a useful strategy for dealing with work-related stress, anxiety, and depression (a common problemencountered in primary health and a major public healthconcern); second, whether or not, the use of appropriatecontrols, randomization, blinding, and a “mental silence-”rather than “relaxation-” orientated approach to meditationcan help answer the question about whether or not medita-tion might have a specific and clinically useful effects.

2. Methods and Materials

2.1. Overview. We designed an 8-week, 3-arm, parallelrandomized controlled trial which compared a “mentalsilence” orientated style of meditation called sahaja yoga

Evidence-Based Complementary and Alternative Medicine 3

to a “relaxation-oriented” meditative control and a wait-ing list (no treatment) control. The trial was conductedfrom 2002 to 2003 in the CBD of Sydney, Australia. Thestudy was approved by the South Eastern Area HealthService Ethics Committee (NSW dept of health) and regis-tered (Trial Registration Current Controlled Trials numberISRCTN46301450).

2.2. Participants. Eligibility criteria were full-time employ-ment (more than 30 hours per week), willing to committo the instructional program and twice daily practice athome, nonsmokers, imbibing less than 2 units of alco-hol daily, free of serious psychological/psychiatric/medicalmorbidity, not using other stress management strategies(including other meditation techniques, methods of relax-ation, or participation in any other organized stress man-agement programs in the past 12 weeks), have expe-rienced no recent major life events (such as bereave-ment/major illness in immediate family, moving house,recent divorce or relationship breakdown), not using recre-ational drugs, willing to fill out a questionnaire batterybefore and after the program. Participants were recruitedby advertising in local newspapers and other popularmedia.

2.3. Interventions. For both active intervention groups,the intervention period was 8 weeks, involving 1-hourevening sessions twice weekly. Participants were requiredto practice twice daily at home for 10–20 minutes eachtime. Compliance with this regime was reinforced at eachinstructional session. Instructors for both active groups werehealth professionals who were also experienced and qualifiedmeditation instructors.

The mental silence meditation (MSM) group was taughtto elicit a state of mental silence or “thoughtless awareness”.The technique is based on Sahaja yoga, a noncommercial,“classical” understanding of meditation. The main techniqueemploys a simple series of silent affirmations based on atraditional understanding of yogic psychophysiology [26].Subjects were encouraged to meditate while sitting quietlyin a chair or in a comfortable position that facilitated theirmeditation experience. The mental silence experience isattainable in several different ways, all of which converge onthe central principle that when the attention is focused onthe experience of the absolute present moment, rather thanevents of the past or future (even the most recent past orimminent future), thinking activity ceases despite remainingfully alert and in control of one faculties. At first, thiscessation of mental activity is short lived but with practiceit can be drawn out into a continuous, enjoyable, experiencewhich meditators consistently describe as peaceful and stress-free [27]. The meditation techniques taught to participantswere simple strategies aimed at facilitating this experience.Affirmations, breathing techniques, and attention focusingexercises were taught in a graded fashion with the emphasisplaced on achieving and maintaining a sustainable stateof “mental silence” (Sanskrit “nirvichara samadhi” or“thoughtless awareness”). Each week informal feedback was

sought by instructors regarding each participants’ progresswith regard to this experiential dimension.

The nonmental silence, relaxation control group (RC)was a generic meditative technique based on the “relaxationresponse” [28]. It was developed by a professional meditationinstructor specifically for the study. Subjects were instructedto sit comfortably, breathing regularly and commence theirmeditation by reflecting on the day’s events. The instructorsought feedback each week from participants in orderto ensure that the meditative style was adhered to. Thisintervention was thus designed to control for nonspecificeffects associated with reduction in physiological arousal(i.e., “rest”) as well as other nonspecific factors such astherapeutic contact, credibility, and expectancy associatedwith any behavioral intervention.

The no-treatment (NT) group was comprised of subjectswho were told that they were on a waiting list to be admittedinto one of the meditation groups at a later date. They werenot told that they were a control group. The waiting NTgroup was included to control for practice effect associatedwith the psychometric questionnaires, regression to themean and other nonspecific effects [29].

2.4. Randomization and Blinding. A research assistantlocated separately from the main investigators randomlyallocated each subject from each round of recruitment toone of the three groups using a blindfolded lottery allocationsystem. The subject was notified of their allocation by theassistant, and this was not disclosed to the investigators.Participants and instructors were blinded to the completehypothesis of the trial, were not informed about whatmethods were being used in the comparison groups, andwere instructed not to disclose information about themethods used in their classes to other trial participants orthe investigators. The investigators, data entry personnel,scorers, and statistician were also blinded to group allocation.The two meditation interventions were structured identicallysuch that nonspecific factors such as credibility, expectation,and demand characteristics were matched as closely as possi-ble. Classes for both intervention groups were conducted atthe same institutional location, in similar rooms, at the sametime of day, with similar support materials; instructionalsessions were of equal duration with equivalent periodsbetween interventions.

2.5. Measures. Baseline assessments were done prior torandomization and at completion upon week eight. Allconsenting potential participants were invited to an eveninginformation session where the basic principles of the studywere outlined, including inclusion and exclusion criteria.Those participants who decided that they were able tosatisfy these criteria were invited to remain and fill outthe baseline questionnaire battery. Any questions or dif-ficulties with the questionnaire were directly addressedby researchers who were also on site at the time ofthe briefing/baseline questionnaire session. Within one,week participants were allocated to their treatment groupand the instructional program commenced. Recruitment


was done in batches in such a way that the informa-tion/baseline questionnaire sessions were not conducteduntil a minimum number of volunteers had accumulated,usually at least 30 per batch. Postintervention assessmentswere similarly conducted between 5 and 7 days after thefinal instructional session, specifically in order to avoidbiasing that may arise from acute effects of the interven-tion.

Consenting participants were assessed on several validmeasures of stress, anxiety, and mood involving: the Psy-chological Strain Questionnaire (PSQ), an accepted measureof work stress and part of the larger Occupational StressInventory (OSI) [30]. The PSQ focuses specifically on thesubjective “work stress” experience, whereas the larger parentquestionnaire assesses environmental stimuli and copingmechanisms as well; the State component of the State/TraitAnxiety Inventory for Adults (STAI) [31]. The state sub-scale of the STAI has been widely used for the assessmentof general anxiety but does not restrict itself to anxiety atwork. We elected not to use the trait subscale as this was ashort-term treatment programme, and we did not anticipateto observe changes in this dimension; and the depression-dejection subscale of the Profile of Mood States (POMS)to assess depressive symptoms [32]. The POMS does notrestrict itself to work stress but addresses general emotionalstates. The GHQ28 was used to assess the mental healthprofile of our sample before treatment. The SERCIS studyused this instrument to assess the mental health profile of anAustralian sample representative of the general population[33]. The GHQ, in its various forms, has been demonstratedto be a reliable estimator of nonspecific psychological distressand demoralization [34].

2.6. Data Analysis. Data was analyzed with the intentionof treating basis. Data for participants lost to followupwas estimated using the last observation carried forward(LOCF) method. SPSS Version 14.0 was used for analyses.Differences in pre- and postscores were calculated for theprimary outcome measures. If the differences were normallydistributed, a one-way ANOVA was used to compare themean differences. For skewed data, a median test of signifi-cance was used to compare frequencies of values above andbelow the median in the three groups. A meaningful changein any of the chosen measures was classified as more than30% improvement (a relatively high threshold) as a positive“improved” clinical response. Those whose score declinedby 15% or more were classified as “declined”. Multiplelogistic regression was used for improved/declined in theoutcome measures. Demographic data were included in thelogistic regression model if they were associated with animprovement with P < .25. Work-related variables includingclassification of occupation were included in a covariateanalysis of work stress variables.

3. Results

3.1. Sample. In total, 250 people fulfilled phone screeningcriteria and attended an information session about the trial

(see Figure 1). Of these, 180 decided to participate and wererandomized to one of three groups. Two people withdrewshortly after randomization, prior to the first class. Thedropout rate at completion of the study was 32% withno significant differences between the groups (χ2 = 1.65,P = .44). The groups had similar characteristics at baseline(see Table 1). Average compliance rate was the same inboth intervention groups (81% attending maximum possibleclasses). Dropouts tended to occur earlier in the MSM group(after 37% of classes were attended) compared to the RCgroup (after 50% of classes attended) strongly suggesting thatcredibility and expectancy was very similar in the two activeintervention groups. The GHQ 28 baseline assessment indi-cated that the participants as a whole were experiencing con-siderably more mental distress than the general population.Using the scoring system recommended by its developers, itis generally agreed that a GHQ score of 5 or more indicateshigh risk of mental health morbidity. The mean score of thereference population from the SERCIS survey was 2.45 (95%CI: 2.3–2.61) [35]. The mean baseline score of our samplewas 7.5. While the SERCIS survey found that 19.5% of thegeneral population had a score indicating mental healthmorbidity, our sample had 47% of participants in the samecategory.

3.2. Outcomes on Stress, Anxiety, and Mood. After adjustingthe data for the primary outcomes on the basis of intentionto treat (LOCF), there was a statistically significant improve-ment for the MSM group (see Table 2) compared to boththe RC and no treatment groups in the median differencesfor occupational stress symptoms (P = .026) on the PSQ,and depressive symptoms (P = .019) on the DD subscaleof the POMS. While an improvement in median differenceon STATE anxiety for the MSM group was noted, it was notstatistically significant (P = .209) within the intention totreat analysis (Figure 2).

The percentage changes in scores for the three primaryoutcomes were categorized into “1” for improvements of30% or more and “0” for changes less than 30%. There wasa statistically significant improvement in occupational stresssymptoms (P < .05; PSQ) and depressive symptoms (P <.001; POMS DD subscale). In the multiple logistic regressionanalysis for occupational stress symptoms, the occupationvariable was included as a covariate. Comparing the no-treatment group with the MSM group showed a significantimprovement in favor of the active intervention (P = .034,OR = 2.64, 95% CI: 1.22–5.68). There was no significantimprovement in the RC group compared to the NT group(P = .546, OR = 1.266, 95 CI: 0.589–2.724). There wasno association between improvement in PSQ and occupation(P = .999, OR = 1.00 95% CI: 0.491–2.033) (Table 3).

In the multiple logistic regression analysis for depressivesymptoms (data not shown), sex was included as a covariate.Comparing the NT group with the MSM group showed asignificant improvement in favor of treatment (P < .001,OR = 5.27, 95% CI 2.38–11.69). There was also a significantimprovement in the RC meditation group compared to


Table 1: Comparison of demographic data and primary outcome measures at baseline.

Demographic Mental silence Relaxation No treatment P value

Mean age (95% CI) 42.5 (39.8–45.2) 41.4 (38.9–44.0) 42.3 (39.4–45.2) .835a

% White collar worker 76% 80% 64% .123b

% > secondary education 46% 57% 45% .501b

PSQ (95% CI) 100.5 (94.6–106.3) 100.4 (94.6–106.3) 99.9 (92.8–106.9) .988a

STATE (95% CI) 41.0 (38.0–44.0) 41.3 (38.5–44.1) 40.3 (37.8–42.9) .869a

DD (95% CI) 14.4 (11.2–17.6) 14.0 (12.0–17.7) 12.3 (9.8–14.8) .384a

aone-way ANOVA; bχ2 test; PSQ: Psychological Strain Inventory; STATE: State/Trait Anxiety Inventory for Adults; DD: Depression Dejection (Subscale of

POMS).

Table 2: Baseline and week-8 median differences on primaryoutcome measures.

Outcomemeasure

Mentalsilence

RelaxationNo

treatmentP value

Median differencePSQ

37.0 22.3 17.5 .026a∗

Median differenceSTATE

−15.0 −8.5 −9.0 .209a

Median differenceDD

−3.0 0.0 0.0 .019a∗

aone-way ANOVA; ∗Significant P < .05; PSQ: Psychological Strain

Inventory; STATE: State/Trait Anxiety Inventory for Adults; DD: DepressionDejection (Subscale of POMS).

Table 3: Responders at completion at week 8 on primary out-comes /= .

Outcomemeasure

Mentalsilence

RelxationNo

treatmentP value

% improving30% + in PSQ

42.4% 27.1% 30.6% .045a∗

% improving30% + in STATE

52.5% 46.4% 44.4% .651a

% improving30% + in DD

59.3% 41.1% 22.2% <.001a∗∗

aone-way ANOVA, ∗Significant P < .05, ∗∗Highly significant P < .01, /=A

percentage improvement of >/=30% was classified as a positive response;PSQ: Psychological Strain Inventory; STATE: State/Trait Anxiety Inventoryfor Adults; DD: Depression Dejection (Subscale of POMS).

the NT group (P = .029, OR = 2.441, 95 CI 1.10–5.43). There was no association between improvement indepressive symptoms and sex (P = .373, OR = .701 95%CI: 0.320–1.534).

4. Discussion

This study has a number of strengths that assert progressin the field of meditation research. First, the use of a largesample, and rigorous methodology, particularly the effortstaken to exclude the effects of nonspecific factors is a notablemethodological strength. This is one of the largest RCTs tomake an earnest attempt to control for nonspecific effectsand one of the only independent RCTs to compare twodifferent conceptual understandings of meditation. Second,

0

10

20

30

40

50

60

Mental silence No treatment

Stress (PSQ)Anxiety (State subscale of STAI)Depression (Depression Dejection subscale of POMS)

Relaxationcontrol

Figure 2: Responder rates for work-related stress, anxiety, andDepression∗. A percentage improvement of >/=30% was classifiedas a positive response at week 8.

in this study there was no evidence of adverse effectsassociated with either intervention since both interventiongroups generated significantly fewer negative respondersthan the untreated group. This is an important though oftenneglected consideration. Third, this study provides evidenceto suggest that a “mental silence” definition of meditationis more likely to be associated with specific benefit. Theimplications of this third point are particularly fascinating,and we discuss some of them below.

A differential effect across the two intervention groupscompared to nontreatment was found in this study. Ourfindings indicate that the mental silence-orientated approachis specifically effective in reducing work-related stress anddepressive feelings. This is the first RCT of this approachto meditation for occupational stress to clearly demon-strate a specific effect in comparison to credible controls(waitlist nontreatment and relaxation). Similar findings wereobserved in an RCT comparing the same approach to med-itation to a standardized stress management interventionfor sufferers of moderate to severe asthma (on prestabilizedtreatment but who remained symptomatic). It demonstratedsignificantly greater improvements in a number of importantsubjective and objective outcome measures associated withmeditation [36].

A field study in which 293 medical practitionerswere taught a meditation skill based on Sahaja yoga for


the enhancement of psychological well-being made a numberof important observations with regard to the relationshipbetween mental silence and the study outcomes [27]. Therelationship between participants’ self-reported experienceof “mental activity/silence” and their self-reported expe-rience of “calm/peaceful” and “tension/anxiety/stress” wasstrong and highly significant, such that the more thatparticipants’ mental activity moved toward the silent state,the more calm/peaceful (r = 0.78, P < .001) and the lesstense/anxious/stressed they felt (r = 0.70, P < .001). In thediary card data, a significant relationship between self-ratedmental silence and K10 score such that a higher self-ratedscore of mental silence was associated with a lower level ofpsychological distress (i.e., a lower K10 score). Among thoseGPs who regarded the intervention as highly effective, therewas a significant positive relationship between the changein mental silence rating and change in K10 score. Takentogether, (this study and Manocha’s field study) suggestan effect not simply attributable to relaxation or placebo,indicating that “reduction of thought activity” has particulareffectiveness for the reduction of stress and stress-relatedillness.

A fundamental challenge for those who design RCTsof meditation is how to develop the behavioral equivalentof a “sugar pill”. In this study, we explore an innovativestrategy to address this challenge. Since reviews such asOspina’s and other thorough examinations of meditationpublished in the literature suggest that the “relaxation”model of meditation generates a predominantly nonspecificeffect then, rather than using it as an intervention, wehave in this study used “relaxation” as a control. In thecontext of this study, by comparing the “relaxation” modelof meditation to a more classical Eastern “mental silence”model this study might not only be understood as a trialthat controls for the important nonspecific effects (placebo,credibility, activity, and physiological dearousal associatedwith relaxation) but also as a head to head comparisonof two differing conceptualizations of meditation. In thisscenario, despite both approaches being “meditative”, theapproach that emphasized the experience of mental silencedemonstrated an effect greater than the one that emphasizesrelaxation.

Conventionally, the stress reducing effects of meditationhave been ascribed to meditation’s ability to reduce physi-ological arousal. Following this line of thinking, the effectsobserved in this study may have occurred because mentalsilence-orientated forms of meditation simply reduce phys-iological arousal more effectively than relaxation-orientatedapproaches to meditation. Alternatively, current theoriesof stress might explain the observed changes as arisingfrom the possibility that mental silence may more effec-tively facilitate greater awareness by reducing distractingand unnecessary mental activity thereby facilitating betterveridical perception, reduced negative affect, and improvedvitality. This contrasts with methods of meditation thatemphasize relaxation, or other models of meditation that donot involve mental silence.

There is some experimental data suggesting that mentalsilence-orientated approaches to meditation might act via

pathways that are different to simple relaxation. For example,Aftanas has conducted neurophysiological trials of the samemental silence-orientated meditation, assessing EEG changesin advanced meditators. The research revealed that thepractice was associated with reproducible brain electricalchanges, and that these patterns correlated strongly withthe specifically defined, self-reported experience [37, 38].A small study in which the same approach to meditationwas compared to rest demonstrated that while those who“rested” manifested skin temperature increases consistentwith the “relaxation response” paradigm, those who med-itated in “mental silence” manifested skin temperaturereduction. Yet the heart rate changes in both groups werenot significantly different. Interestingly, the degree of skintemperature reduction in the meditation group correlatedhighly with meditator’s self-reported experience of mentalsilence [39]. The skin temperature changes suggest that apotentially unique fractionation of the relaxation responseoccurs in association with the mental silence experience. Thisimplies that the mental silence-orientated conceptualizationof meditation may be associated with specific physiologicalchanges. Perhaps these changes are responsible for thespecific effects observed in this study. Future studies of thisapproach to meditation should therefore correlate clinicaland behavioral changes with convention measures of arousal.

Until 2006, the U.S. National Center for Complementaryand Alternative Medicine (NCCAM) defined meditation as“a conscious mental process that induces a set of integratedphysiological changes termed the relaxation response” [40].Remarkably, however, in 2006 the NCCAM reviewed itsdefinition of meditation, describing a new central feature: “Inmeditation, a person learns to focus his attention and suspendthe stream of thoughts that normally occupy the mind.” [41]The fundamental change in emphasis from the physiologyof rest (a Westernized understanding of meditation) to theexperience of “suspension of thought activity” (a moreclassical eastern idea of meditation) raises an importantquestion about whether or not this shift in conceptualizationhas practical and clinical significance. Our study throwssome important empirical light on these theoretical andphilosophical shifts. On a more theoretical level, medita-tion is popularly perceived as having specific effects. Infact historical tradition, especially Eastern tradition, assertsthat meditation has a unique effect and yet the scientificevidence, based mainly on studies of Westernized modelsof meditation, does not agree with these perceptions. Theoutcomes of this trial suggest that one way to resolve thisconundrum may be to propose a definition of meditationbased on the “experience of mental silence”.

We do acknowledge limitations to this study. Ourprimary research question was whether or not mental silencemeditation had a specific effect on work stress and this is bestassessed at the postintervention point; therefore, this trialdid not incorporate a follow-up assessment. In light of theoutcomes of this study, future studies warrant a follow-upassessment strategy to assess whether participants continueusing the intervention and the degree to which the benefitsare maintained. The use of instruments such as the PSQ,DD, and STATE in our study may be considered by some


as not adequately objective, but it should be noted that theuse of such measures is currently considered to be both areliable and standard approach to studying the effects ofinterventions for work stress. There is good evidence thatthese measures are clinically useful and reliable and in fact,although more objective measures might be more desirablein studies like this, there is currently no agreement amongstwork stress researchers about which objective measures areboth reliable and feasible for use in field studies.

The use of intention to treat analysis in this study is likelyto give a very conservative understanding of the independentvariable’s impact. The dropout rates in our trial were similarto other trials of meditation for work stress and meditationtrials in general. The dropout rates in the two groups werenot significantly different, and there were no significantdifferences between the dropouts and finishers in baselineand demographic data suggesting that their exit did notintroduce any major selection bias. Compliance measureswould be theoretically useful as a covariate in the analysisof the outcome data. We did not, however, assess homecompliance directly because our experience in pilot studieswas that assessments such as daily practice diaries were notsufficiently reliable. We did not assess credibility of the twoactive interventions. This is a potential drawback howeveras both were legitimate interventions in their own right.Moreover, the fact that dropout rates in both groups werenot different strongly suggests that both interventions weresufficiently and similarly credible. This trial required subjectsto attend after normal working hours at a site separate fromtheir workplace, however, future trials that are well integratedinto daily activities within an organization may generatesignificantly lower dropout rates. Finally, the recruitmentof participants working in the CBD of Sydney in the studythrough newspapers and other media means that inferencesfrom the study can only be made to the population definedas responding to the media of an industrialized area with amainly Caucasian population.

5. Conclusion

This study provides preliminary evidence to support theuse of a mental silence form of meditation called SahajaYoga to reduce work stress and depressed mood. While theresults are encouraging, further research is now requiredto validate and explore these findings. Given the low-cost,noncommercial nature of the intervention, and the low riskof adverse effects it would not be unreasonable to suggestthat this meditation would be useful as a health enhancingstrategy with potential for significant socioeconomic benefitto individuals and society.

This trial provides initial evidence indicating that thereare measurable, practical, and clinically relevant differencesbetween two differing conceptualizations of meditation. Ona practical level Sahaja Yoga, and by inference, possiblyany meditation technique that is specifically mental-silenceoriented, is safe and effective as a general interventionstrategy for dealing with work stress. It suggests that thoseforms of meditation that emphasize “thought reduction” or

“mental silence” may have specific effects beyond simplerelaxation techniques that may be relevant to health care.The fact that this trial was a field study of a group withdemonstrably higher levels of psychological distress whencompared to available population norms strongly suggeststhat the intervention is feasible and relevant in the “realworld”.

Acknowledgments

The authors gratefully thank the Natural Therapies Unit,Royal Hospital for Women and the Institute of Neu-ropsychology, Swinburne University, Dr. Greg Turek andMr Robert Hutcheon. Dr. Jerome Sarris is funded by anAustralian National Health & Medical Research Councilfellowship (NHMRC funding ID 628875), in a strategicpartnership with The University of Melbourne and the BrainSciences Institute at Swinburne University of Technology.they thank the Sahaja yoga meditation instructors whovolunteered their time and skills without charge. The authorsdid not develop the meditation technique, and they gratefullyacknowledge its developer Shri Mataji Nirmala Devi whopermitted its use on the proviso that its noncommercial,open-access ethos was maintained.

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Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2012, Article ID 350674, 9 pagesdoi:10.1155/2012/350674

Research Article

Quality of Life and Functional Health Status of Long-TermMeditators

Ramesh Manocha,1 Deborah Black,2 and Leigh Wilson2

1 Discipline of Psychiatry, Sydney Medical School, University of Sydney, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia2 Faculty of Health Sciences, University of Sydney, Cumberland Campus, Lidcombe, NSW 2141, Australia

Correspondence should be addressed to Ramesh Manocha, [email protected]

Received 9 October 2011; Revised 15 January 2012; Accepted 15 January 2012

Academic Editor: Guillermo Schmeda-Hirschmann

Copyright © 2012 Ramesh Manocha et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. There is very little data describing the long-term health impacts of meditation. Aim. To compare the quality oflife and functional health of long-term meditators to that of the normative population in Australia. Method. Using the SF-36questionnaire and a Meditation Lifestyle Survey, we sampled 343 long-term Australian Sahaja Yoga meditation practitioners andcompared their scores to those of the normative Australian population. Results. Six SF-36 subscales (bodily pain, general health,mental health, role limitation—emotional, social functioning, and vitality) were significantly better in meditators compared to thenational norms whereas two of the subscales (role limitation—physical, physical functioning) were not significantly different. Asubstantial correlation between frequency of mental silence experience and the vitality, general health, and especially mental healthsubscales (P < 0.005) was found. Conclusion. Long-term practitioners of Sahaja yoga meditation experience better functionalhealth, especially mental health, compared to the general population. A relationship between functional health, especially mentalhealth, and the frequency of meditative experience (mental silence) exists that may be causal. Evidence for the potential role of thisdefinition of meditation in enhancing quality of life, functional health and wellbeing is growing. Implications for primary mentalhealth prevention are discussed.

1. Introduction

Meditation is widely perceived as an effective method ofreducing stress and enhancing wellbeing. The US Centersfor Disease Control and Prevention’s 2002 National HealthInterview Survey administered to 31,000 representativeadults showed that 8% of respondents had practiced medi-tation at some time [2]. The Australian Community Surveyfound that 1.5 million Australians had tried meditation inthe past 12 months and that while 29% of Australians foundprayer to be a source of peace and wellbeing, 24% usedmeditation for the same thing. Remarkably, despite onlyabout 20% of Australians attend church monthly or moreoften, around 33% of Australians pray or meditate at leastweekly [3, 4].

Health professionals are also enthusiastic about medita-tion despite a lack of formal education about it; a surveyof Australian GPs found that almost 80% of respondents

had recommended meditation to patients at some time inthe course of their practice, yet less than 35% had anyformal training or education in the field [5]. Mindfulness hasbecome particularly popular in recent years both amongstconsumers and health professionals. The growing popularityof meditation as a lifestyle and health enhancing strategywarrants more detailed assessment of its impacts on thosewho choose to practice it regularly over long periods of time.In spite of this, there remains a lack of evidence about thelong-term health effects of regular meditation [6, 7].

Despite the fact that there are hundreds, if not thousands,of interventional studies of meditation in the literature, theyare limited to relatively short durations of practice, usuallyseveral weeks [8]. Yet meditation, as it was traditionallyconceived, was intended to be a life-long practice, the benefitsof which were not necessarily expected to manifest in theshort term. Unfortunately, interventional studies to assessbenefit (or detriment) over periods of years and decades

mailto:[email protected]


Table 1: Demographics of meditation practitioners.

Factor Meditation practitioners∗

Number of responses 343

% Male 39.6

Mean age and age range44, (SD 13.4), range 18 yrs

to 82 yrs

% Caucasian 77.2

% Asian 21.9

% Single/nevermarried/divorced/widow

27

% Married/de facto 73

High school, highest level 25.9

Undergraduate, highest level 49.4

Postgraduate, highest level 21.2

No history of mental illness 87.9

History of minor mental illness 10.4

History of major mental illness 1.7∗

In comparison, the National Health Survey in 1995 was weighted topopulation norms with the SF36 administered to only the householdmembers aged 18 years or more. The mean age was 42.6 (SD 16.5) with 48%male.

Table 2: Meditation lifestyle of practitioners.

Meditation lifestyle dataMeditation

practitioners

Total responses (n) 343

Mean duration of practice (years) 12.9

% who meditate regularly 95.6

% Formal meditation, twice/day 51.2

% Formal meditation, once/day 31.8

% Formal meditation, most days 12.1

% Formal meditation, once/week or less 5

% Group meditation, once/day or more 10.1

% Group meditation, most days 10.2

% Group meditation, once/week 60.5

% Socialize with other practitioners most days ormore often

11.6

% Socialize with other practitioners once/week 37.8

% Socialize with other practitioners less thanonce/week

50.6

% who do not consume alcohol 92.3

% who do not smoke 92.6

% who do not use marijuana or other recreationaldrugs

98

are difficult to accomplish and are prone to a wide rangeof confounding effects and logistical challenges. Meditationoriginated as spiritual practice in India, initially linked withHindu spiritual philosophies such as yoga, later spread morewidely in association with Buddhist spirituality to the orient.In different places, it underwent transformations giving riseto traditions such as Zen. Since the early 20th century,meditative practices, along with Eastern spiritual ideas, have

become popular in the West, and in the last few decades theyhave become the focus of scientific attention.

Independently of this, a growing body of mostly epi-demiological evidence has emerged pointing to a significantassociation between what has come to be termed “religiosity”and health [9]. Studies of specific religious groups point tothe positive impact of prayer and religious practices on health[1]. Pertinent examples of this relationship are the numerousstudies in Seventh Day Adventists and Meisenhelder’s 2001study investigating Presbyterian pastors [1, 10]. Studiesdemonstrate that Seventh Day Adventists exhibit specificphysical health advantages when compared to non-SeventhDay Adventists. These include a reduced risk of coronaryheart disease and reduced prevalence of chronic conditions.Most of this health benefit appears secondary to the relativelyspecific diet and lifestyle of Seventh Day Adventists, whichincludes avoidance of alcohol, tobacco, and meat [10].

Assessment of 1400 Presbyterian pastors by Meisenhelderand Chandler [1] showed that this group had considerablybetter health compared to USA population norms. Aftercontrolling for age and other demographic variables, asmall correlation was found between frequency of prayerand certain important health dimensions, particularly men-tal health, vitality, and general health. The investigatorshypothesised that this correlation may be due to the directeffects of prayer, which induces a “meditation-like state”of reduced physiological arousal and includes a dimensionof psychological support derived from seeking solace in “adivine other” [1].

Despite the abundance of short term interventional trialsof meditation, there is very little in the literature regarding itslong-term impacts or its influence on population health. Weidentified only two notable studies: Reibel investigated healthrelated quality of life and the practice of meditation in a long-term context. In a year-long observational study of an 8-weekmindfulness meditation program involving 136 participants,one year after the initial intervention, participants’ chronicillness, physical symptoms, and pain had reduced by 28%and psychological distress decreased by 38% [11].

The only other long-term study of meditation was aretrospective assessment conducted by Otis in 1984 [11].Otis followed up over 1,000 people who had participatedin a student meditation instructional programme at theStanford Research Institute and, counter-intuitively, foundthat long-term practitioners of meditation described a rangeof negative effects of the practice. These included antisocialbehaviour, anxiety, confusion, and depression and correlatedwith the length of time the participants had been practicingmeditation. Thus the only two studies aimed at assessingthe long-term impacts of meditation present a contradictorypicture.

Importantly, despite the large number of interventionalstudies of meditation in the literature, the vast majorityare not properly designed to control for confounding,nonspecific effects. Much of this oversight relates to thelack of clarity around the definition of meditation. Onedefinition that has yielded evidence for specific effect inrigorously designed trials is a paradigm of meditation thatfeatures the experience of “mind-emptiness” or “mental


Table 3: Comparison of SF-36 subscale scores between mental silence practitioners and Australian national norms.

Subscale Test value (national norm) T Df Significance Mean difference

PF 83.82 1.75 345 0.082 2.39

RP 80.64 −0.95 345 0.342 −2.10

BP 77.05 3.19 345 0.002 3.79

GH 71.81 12.72 332 0.001 10.72

V 64.27 6.24 337 0.001 5.98

SF 85.25 3.59 337 0.001 3.52

RE 83.44 4.43 334 0.001 5.74

MH 75.75 14.26 336 0.001 9.56

Table 4: Correlation of frequency of mental silence experience (MS) and SF-36 scores.

PF RP BP GH V SF RE MH PCS MCSTotalSF-36

MSPearson

Correlation−0.039 −0.099 −0.005 −0.200∗∗ −0.217∗∗ −0.030 −0.097 −0.345∗∗ −0.125∗ −0.243∗∗ −0.175∗∗

n 341 341 341 330 335 335 333 334 326 316 316

n: number of samples∗: 0.05—Probability of a Type I error∗∗: 0.01—Probability of a Type I error.

silence” as its defining characteristic [12]. Sahaja Yoga is anoncommercial form of meditation and is an example ofthis form of the mental silence approach. In this context, themeditative experience is a state in which the practitioner isfully alert, aware, and in control of their faculties but doesnot experience any unwanted thought activity. Practitionersdescribe the experience of thoughtless awareness or “mentalsilence” as an enhancement of awareness and self-control,enabling them to attend to the demands of the presentmoment [12]. Studies of the mental silence approach tomeditation have been conducted in a range of healthconditions [13]. Rigorous randomised trials using activecontrol groups have demonstrated significant effects onmood and airway hyperresponsiveness in asthma sufferers[14] and on depressive mood and work stress in full-time workers [15]. In other studies, promising effects havebeen shown in depression/anxiety [16, 17], attention deficitand hyperactivity disorder [18], menopausal hot flashes[19], and epilepsy [20]. Brain physiological studies indicatethat the meditative experience is highly correlated withspecific electrical activation patterns [21]. Thus short-termobservational trials support the premise that this techniquehas measurable specific effects. Data on its long-term effectshowever are, like most meditation techniques,unavailable.

It is interesting that while epidemiologists have focusedon the associations between western (i.e. Judeo Christian)styles of religiosity and health, health professionals, especiallymedical and psychological, have been focusing on the healtheffects of eastern (i.e., meditation) styles of religiosity. Clearlythere is much to be gained by bringing these two strands ofinvestigation together.

Consequently we designed this study to both providedata regarding the association between several aspects ofquality of life, functional health, and wellbeing in a group of

people who practiced long-term mental silence meditation,as well as attempt to unify some the data on the relationshipbetween practices that have their origin in either eastern orwestern religious tradition. We report here the data relatingto the quality of life and functional health measures.

2. Aim

The primary aim of this study was to compare the quality oflife and functional health of a sample of the population whohave practised long-term mental silence meditation to that ofthe normative Australian population. A secondary aim wasto explore the relationship between health scores, meditativepractice, and meditative experience (mental silence—MS).We report here the data relating to the SF36.

3. Method

3.1. Study Design. This cross-sectional survey aimed tocollect data concerning quality of life and health function-ality. We report here the outcomes relating to the MedicalOutcomes Study Short Form (SF-36) and the MeditationLifestyle Survey (MLS). The MLS was developed specificallyfor the purposes of this study. The study was approved by theResearch Ethics Committee of the University of New SouthWales.

3.2. Recruitment. Sahaja Yoga Meditation (SYM) Centresaround Australia were contacted and asked to participate ina cross-sectional study investigating long-term meditationpractice. A researcher, no reference needed, travelled toeach of the capital cities of Australia and attended themain meditation meeting in each centre. The researcher alsoattended five one-day and weekend meditation retreats held


Table 5: Comparison of the MH score for each MS category with Australian normative values for MH score.

TA Category Number in sample MS category mean score MS category score SD T Df Significance Mean difference

Several times per day 172 87.98 10.04 15.97 171 0.001 12.22

Once or twice per day 98 85.35 10.46 9.07 97 0.001 9.59

Once or twice per week 38 81.05 12.04 2.71 37 0.010 5.30

Once or twice per month 13 74.46 22.30 −0.21 12 0.838 −1.29

Less than once per month 13 71.69 21.45 −0.68 12 0.508 −4.06

Table 6: Comparison of SF-36 subscales study results with those of Meisenhelder and Chandler [1].

Meisenhelder and Chandler [1] This study

Subscale Frequency of prayer r Significance Frequency of mental silence r Significance

PF −0.001 0.965 −0.039 0.474

RP −0.010 0.715 −0.099 0.067

BP 0.037 0.166 −0.005 0.928

GH 0.088 0.001 0.200 0.001

V 0.103 0.001 0.217 0.001

SF 0.027 0.317 −0.030 0.586

RE 0.039 0.154 −0.097 0.077

MH 0.117 <0.001 0.345 0.001

between six and ten times per year to promote the study.Participation in the study was voluntary and anonymous.At the commencement of each meeting/retreat, the studypurpose was explained in detail, as was the anonymous andconfidential nature of participation. Sahaja Yoga MeditationCentres do not keep formal membership lists; howeverinformal lists of phone contacts were used to identify otherpractitioners who may not regularly attend meetings but stillconsider themselves diligent practitioners.

3.3. Sample Size. The researcher attended seven meetingsand five weekend retreats. In total, 336 practitioners ofmeditation attended one of these meetings or retreats. Atotal of 311 practitioners completed the questionnaire andsurvey at these meetings/retreats/weekends. Examination ofthe informal lists revealed a further 215 records; they werecontacted and mailed a set of questionnaires. A total of 32(6%) responded from this group. In total, 343 responses wereavailable for detailed analysis, representing approximately63% of the total purported SYM practitioner communityin Australia or 93% of those practitioners who might bedescribed as “diligent, long-term practitioners”. While thesampling design was opportunistic, the response rate of thesurvey was such that it was effectively a census. In this contextit is reasonable to assume that nonresponder demographiccharacteristics are highly likely to be similar to those of theresponders.

3.4. Questionnaires

3.4.1. Medical Outcomes Study Short Form 36 Questionnaire(SF-36). The Medical Outcomes Study Short Form 36 (MOSSF-36) is a widely used health and quality of life self-reportquestionnaire. Eight domains of health are evaluated in the

SF-36, each relating to a specific valence of health experience:bodily pain (BP), general health (GH), mental health (MH),physical functioning (PF), role limitation—emotional (RE),role limitation—physical (RP), social functioning (SF), andvitality (V). It has been used extensively in Australia forboth population health and clinical applications and hencepopulation norms exist for the SF-36. The Australian normswere collected in the 1995 National Health Survey as thisinstrument has not been used in subsequent national healthsurveys [21].

3.4.2. Meditation Lifestyle Survey (MLS). The MeditationLifestyle Survey is an instrument developed specifically forthis study. The aim of the survey was to provide a number ofcovariates to assist with the analysis of the SF36 data. Thescales involved yes/no answers for demographic questionsin addition to ordinal type questions about meditative andlifestyle practices. The factors were developed in consultationwith a number of experienced meditators and experts toensure face validity and interrater reliability.

Most of the items in the survey were aimed at assessingthe frequency of meditative practice among meditationpractitioners to determine their level of adherence to lifestylefactors associated with meditation. Potentially confoundingvariables in the practitioner’s lifestyle were also includedin the MLS Survey. The primary factor of interest was theexperience of mental silence or “thoughtless awareness”. Therationale of the lifestyle practices associated with meditationis that they are intended to maximize the meditation prac-titioner’s ability to tap into the mental silence experience.Conceptual validity analysis of the MLS (in the analysis andresults section of this paper) demonstrates that it explainedat least 75% of the variance in practitioners self-reportedexperience of mental silence, indicating that the MLS was


effective in capturing the salient factors in the mediators’lifestyle.

At each meeting or retreat, participants who wereprepared to participate in the study were asked to completean SF-36 questionnaire and an MLS survey. Those who didnot attend the meeting, but had been identified throughinformal lists, were contacted by a research assistant. If theyhad not previously completed a questionnaire and survey,they were mailed copies with a reply paid envelope. Eachperson was phoned by a research assistant (after four weeks)to maximize return rates.

3.5. Analysis. Statistical analysis was conducted using SPSSversion 17.

To compare the scores on various subscales of the SF36with the national normative data t-tests were conducted. Weused a Holm-Bonferroni correction for multiple testing. Thevalues presented in this report are those derived after thisadjustment.

To explore the degree to which aspects of medita-tive practice contribute to health scores, the relationshipsbetween various demographic and meditative lifestyle factorsfrom the MLS with outcomes in the SF-36 were examinedusing Pearson Product Moment correlations.

A multiple regression analysis was conducted to explorecolinearity between the various demographic factors, medi-tative lifestyle factors, health scores, and the MS experience.The total SF-36 and certain subscales were selected as depen-dent variables. Since the MLS was constructed around thenotion that the experience of mental silence is facilitated bythe various practices and lifestyle factors featured as items inthe MLS, these items were included in the regression analysis.In addition, demographic factors known to independentlyinfluence physical and mental health were also included asfactors in the regression analysis. This included age, gender,relationship status, history of mental illness, educationallevel, ethnicity, consumption of alcohol, tobacco, marijuana,and other recreational drugs and social support. In this casefrequencies of attending social gatherings and other meetingsof meditators were interpreted as social support.

4. Results

4.1. Demographic Data. Demographics of the 343 medita-tion practitioners who participated in the study are detailedin Table 1. Meditation lifestyle data are summarised inTable 2.

4.2. The Experience of Mental Silence. Just over half of thesample (51.9%) claimed to experience the state of mentalsilence or “thoughtless awareness” for more than one or twominutes several times a day. A little over one-quarter (28.6%)experienced this state once or twice day. Approximately one-tenth, 11.3%, experienced mental silence once or twice perweek. A much smaller proportion experienced it less often.

4.3. Functional Health. Functional health scores for themeditators were high. A total of 92% of the respondents

86

79

8183

70

89 89

85

84

72

64

85

76

55

60

65

70

75

80

85

90

95

PF RP BP GH V SF RE MH

Scor

e

SF-36 subscale

81 83

77

Background populationLong term SYM practitioners—whole population

Figure 1: SF-36 polygon for Australian national norm data andmental silence sample.

described their health is as “good” or better (“excellent”(28.6%), “very good” (43.8%), or “good” (19%)). Nearlyhalf, 48.6% described their health as “much better” or“somewhat better” than a year ago, while 45.7% describedtheir health as “about the same” as a year ago, while88.1% agreed that their health was “definitely” or “mostly”excellent.

A more precise understanding of the differences can beappreciated by inspecting the comparison of the Australiannormative data for the SF-36 with the meditators’ measures.These results are quite striking and are illustrated in Figure 1and summarised in Table 3.

The largest differences appear to be in the mental health(MH), role-limitation emotional (RE), and general health(GH) subscales. All differences except physical functioning(PF) and role limitation physical (RP) were significant(p<0.005) (see Table 3).

4.4. Correlations. To identify any potential relationshipsbetween the frequency of formal meditation (FM) andhealth, the means of the various SF-36 subscale scores werecalculated for each FM category. No significant relationshipbetween FM scores and SF-36 scores was observed. Themeans of the various SF-36 subscale scores were thencalculated for each mental silence (MS) category to facilitatecomparison. A linear relationship was apparent for the Men-tal Health (MH) subscale, which is illustrated graphicallyin Figure 2. A central notion in this study is the idea thatthe experience of mental silence may be a factor associatedwith the beneficial effects of meditation. In line with this,the simple correlations clearly demonstrate that MS is the


60

65

70

75

80

85

90

Seve

ral t

imes

per

day

or m

ore

Au

stra

lian

ave

rage

men

tal h

ealt

h s

core

On

ce o

r tw

ice

per

day

On

ce o

r tw

ice

per

wee

k

On

ce o

r tw

ice

per

mon

th

Less

th

an o

nce

per

mon

th

∗∗

∗

Figure 2: Mental Health subscale score for each category offrequency of mental silence (thoughtless awareness) experience.

factor most commonly and most strongly correlated with thevarious health scores.

Pearson Product Moment calculations comparing the SF-36 total, the PCS, the mental health summary score (MCS),and the SF-36 subscales with MS raw scores were calculatedrevealing a number of notable correlations. These data aresummarized in Table 4.

Linear relationships with frequency of meditation wereapparent for mental health (MH), general health (GH),vitality (V), mental health summary score (MCS), and SF-36total score. The most clearly obvious linear association waswith the MH subscale.

Two demographic factors, salary and history of mentalillness, were excluded from this investigation, because theywere likely to be proxies for the dependent variables ofinterest. Several significant relationships became apparent.

To develop an impression of the individual contributionof various constructs to the total variance in the SF-36 totalscore, a further set of GLMs was applied. The relationshipbetween the MLS factors and the SF-36 total score (SF-36),the physical health summary score (PCS), the mental healthsummary score (MCS), and the eight subscales, was assessed.The strongest correlations occurred consistently in relationto mental silence.

Comparing the MH score of each MS category demon-strates that the mean score of the first three categories for thissample is significantly higher than the national norm scorefor the same category (Table 5).

4.5. Assessment of the MLS. One of the aims of this studywas to investigate how the practice of meditation and,more specifically, the meditative experience of mental silenceor “thoughtless awareness” may be related to mental andphysical health outcomes. The experience of mental silenceis thought to be facilitated by the various practices andlifestyle factors featured as items in the MLS. These includegroup meditation with other meditators, attending weeklymeetings to socialize, meditate with, and learn more about

meditation techniques, regular meditation, “foot soaking”(FS) and associated techniques, and duration of practice(DP).

4.6. Conceptual Validity of the MLS. In order to evaluatethe conceptual validity of this instrument, we tested theMLS and the relationship between the items (as independentvariables) and MS (as the dependent variable). To explorethe degree to which the MLS predicted MS when controllingfor various demographic and MLS factors and their potentialinteractions, a general linear model (GLM) was used. In thismodel the independent variable was MS, and the dependentvariables were duration of practice (DP), regular meditation,and foot soaking (FS).

The covariates were all other MLS and demographicfactors and a number of appropriately selected interactionsbetween these covariates. The GLM had an r2 of 0.736and thus the model explained almost three-quarters ofthe variation. In this model, the significant factors weregender (P < 0.05), alcohol consumption (P < 0.005),marijuana/recreational drug consumption (P < 0.01), CM(P < 0.05), regular meditation (P < 0.05), durationof meditation practice (DP) (P < 0.005), the interactionbetween foot soaking (FS) and regular meditation (P <0.005), and the interaction between FS and DP (P < 0.05).The r2 value indicates that the MLS effectively captures themajority of factors that explain how often the practitionerexperiences mental silence.

To investigate the contribution of MS to the SF-36 score, aGLM was applied with only MS as the independent variable,resulting in an r2 of 0.46. In order to contrast this with theindividual contribution of FM, another GLM was appliedwith FM as the independent variable, resulting in an r2 of0.019.

The relationships observed in this study are not entirelyunprecedented. Meisenhelder’s 2001 survey of Presbyterianministers using the SF-36 as well as measures of prayerhabits found that the sample had somewhat better healththan national norms. Remarkably, frequency of prayercorrelated significantly with the same subscales of the SF-36in Meisenhelder’s study as that for meditation in this study(Table 6).

5. Discussion

The difference in scores on the SF-36 between the meditatingpopulation and the general Australian population is sub-stantial and wide ranging. The apparent positive differencesbetween the sample of meditation practitioners and thenational norms may be the result of confounding factors.In an attempt to control for this, and although somewhatlimited by the nature of the Australian National HealthSurvey dataset, even when comparing the health scoresof that portion of the population that does not consumetobacco (the only factor that the ABS dataset allowed us tocontrol for) but has the same age profile as the meditatorssample, the significant differences persisted.


George and colleagues noted in their discussion aboutthe nature and quality of samples used in surveys andlongitudinal studies of religious practices that more thanhalf of the studies that address the relationship betweenreligion and health are based on samples of older adults(60+ years of age) [22]. Epidemiological study of religiosityand its relationship to health is currently dominated by aWestern, Judeo-Christian perspective. George further notedthat these kinds of studies are usually conducted withinlimited geographic regions within the USA and are thuspotentially influenced by regional variations in religiousobservance (e.g., Bible Belt states versus West Coast). Incontrast, this study involved a national, representative sampleof meditators, the sample group was relatively young (witha mean age of 37), and its outcomes were comparedto national, census-based normative data. An additionalstrength of this study is that it examined non-Judeo-Christian religiosity in a country comparable to, althoughnot geographically connected to, the USA, on a sample ofrespondents who are ethnically similar and yet religiouslydifferent.

The meditator population may well be selected for thosewho are more motivated to achieve and maintain health.Various surveys have shown that people who use meditationand other forms of complementary and alternative medicinehold strong affiliations with holistic health philosophiesand are highly motivated to seek out self-empoweringhealth improvement strategies. It is quite possible that apopulation of long-term meditation practitioners would behighly selected for such people. Moreover, those practitionerswho do not experience positive effects or even experiencenegative effects naturally desist from the practice and attritfrom the meditating population, further improving the meanhealth scores of the remaining population.

Surveys of this nature necessarily generate a level ofexpectancy among respondents. The responses of the long-term meditating population could have been influenced bythe prospect of the survey results constituting a validationof their chosen lifestyle and belief system. Nevertheless, thefact that the overall pattern of response in the meditatingsample follows a similar pattern to that of the Australianpopulation provides some reassurance that this was not amajor confounder. Furthermore, the data reported here arealmost exactly the same as the data obtained in two pilotsurveys.

It is important to note that while modern sciencemost commonly characterises meditation as a relaxationresponse or a pattern of specifically focused attention, theseconceptualisations differ fundamentally from the authenticdescriptions of the meditative experience originating inancient India. The original source texts clearly state that akey defining feature of meditation is the experience of mentalsilence. For example, in what is probably the oldest knowndefinition of meditation, the narrator explains in the ancientIndian Mahabharata that a meditator is “. . .like a log, hedoes not think” [23]. Similarly Lao Tse instructs the readerin the Tao Te Ching to “empty the mind of all thoughts”.Many other explicit examples of this idea can be found inEastern literature from virtually every historical period. Yet

Western definitions of meditation have consistently failed toacknowledge this crucial feature.

The mechanisms by which meditation techniques exerttheir claimed effects are also unclear. One very popular view,which has become more or less the default explanation,is that the physiological changes are characterised by therelaxation response—that is, the physiological changes thatoccur during rest, characterised by reductions in heartrate, blood pressure, and respiratory rate and increases inskin temperature, skin resistance, and alpha wave activityin the brain are thought to be responsible. All of theseare brought about by reducing activity of the sympatheticcomponent of the autonomic nervous system and increasingactivity of the parasympathetic components of the ANS.Psychophysiological studies of Sahaja Yoga, that is mentalsilence, however suggest that it does not elicit a typicalrelaxation response. For example, a study of skin temperaturechanges during a single Sahaja Yoga meditation sessiondemonstrated a reduction in palmar skin temperature, whichis the opposite of that predicted by the relaxation responsemodel. A control group that was engaged in simple restdid manifest skin temperature increases. Yet there were nosignificant differences in heart rate between the two groups[24].

In her 2001 study, Meisenhelder proposed that therelationships observed between frequency of prayer andhigher health scores could at least be partly caused by therelaxation effect of prayer and its consequent ability toameliorate the effects of stress. This idea is supported bystudies such as that by Carlson who studied the autonomicimpact of Christian devotional meditation in an RCT designand found that it was as effective, and in some parametersmore effective, as conventional relaxation [25].

So, it is noteworthy that both this study and the studyby Meisenhelder and Chandler [1] report correlations in thesame SF-36 subscales (general health, vitality, and mentalhealth) suggesting that both prayer and meditation areboth associated with similareffects. An interesting distinctionhowever is that our study suggests that the experience ofmental silence has a stronger (by a factor of approximatelytwo to three) relationship with these dimensions as com-pared to the relationship that Meisenhelder reports betweenprayer and the same dimensions. The notion that this may bedue to some inherent effect of the mental silence experienceis supported by the two RCTs on work stress and asthma,mentioned earlier, and clearly warrants further investigation.

The observed relationship between how often a medi-tator performed “formal meditation” and health measureswas considerably weaker than for mental silence, implyingthat differences between contemplative practices (such asprayer or meditation) that are overtly similar but sometimesexperientially distinct (i.e., mental silence versus mentalactivity) have significantly different health implications.

The observed relationship between meditative practicesand mental health is not as strong as for measures ofphysical health. In many ways, this might be expectedsince the intervention is primarily focused on a mentalexperience with the specific aim of reducing negative affect,thinking patterns, and related behaviours. Mood, thoughts,


and behaviour patterns are in constant flux, much of itreflecting (and influencing) brain electrochemical activityand other neurobehavioural phenomena which change frommoment to moment.

There is evidence that meditation can have short- andlong-term effects on both function and structural brainplasticity in addition to its already recognised ability to causerelaxation and reduce stress. Aftanas has shown that thepractice of SYM, and the experience of mental silence, isstrongly reflected in both brain electrophysiology and mood[26]. A study by the same group demonstrated reducedemotional reactivity in long-term meditators compared tocontrols which was reflected in psychological, physiological,and electrophysiological reactivity to standardised stressfulstimuli presented in a video film. This provides evidence forthe notion of “emotional detachment” and hence enhancedemotional stability and resilience to stressful events [27].A smaller intervention study by Morgan over just 6 weeksshowed a significant reduction in anxiety, depression, andrelated symptoms in patients with major depression com-pared to controls [17] which appears to reflect the clinicalrelevance of Aftanas’s findings. This has broader implicationsparticularly as understandings of the relationship betweenneuroplasticity and meditation emerge. Lazar studied agroup of Buddhist meditators and found that meditatorscompared to controls had significantly increased corticalthickness in right middle and superior frontal cortex andinsula suggesting that meditation is associated with delayingof the usually age-related thinning of right frontolimbicbrain regions [28]. Hence it is quite possible that long-term meditation may facilitate both electrophysiological andstructural changes in brain function that may explain whythe population of long-term meditators that we studiedmanifested an apparent advantage as compared to the back-ground population particularly in metal health scores. Anexcellent review and discussion paper by Rubia [29] discussesthe possible neurobiological underpinnings of meditationand its potential role in mental health in detail that is notpossible within the limits of this paper.

These observations might also explain why mental healthfactors are much more likely to be immediately responsive tosuch an intervention whereas physical health factors, whichrely significantly on anatomical structures and mechanicalfunction, will take much longer to manifest (if at all) and aresubject to a vast number of other environmental confoundersthat may obscure any such relationship.

While we acknowledge that cross-sectional studies areprone to a number of confounders, the implications for pop-ulation mental health are nevertheless worth considering.Given that neuropsychiatric disorders such as depression andsubstance abuse are increasing in incidence as well as theirimpact and that there are few long-term curative options formany of these conditions, there is merit in exploring the roleof preventative strategies such as meditation. The findingsof this study warrant further examination of meditativepractices as a conceptually innovative preventative andtherapeutic option for public mental health. The meditationtechnique assessed in this study is low/zero cost and todate has not been associated with any adverse effects; hence

further exploration of this approach in enhancing generalwellbeing, quality of life, and mental health would seem tobe highly worthwhile.

6. Conclusion

This is the first study to report a cross-sectional surveyaimed at assessing health and quality of life in a populationof people who meditate regularly and have done so for along period of time. It is also the first study to explorethe interrelationship between factors such as meditativeexperience, meditative practices, a “meditative” lifestyle, andhealth outcomes.

Long-term Sahaja Yoga meditation practitioners appearto experience better quality of life and functional healththan the general population. Perhaps most importantlyis the observation that there appears to be a relativelyrobust and consistent relationship between the meditativeexperience of mental silence and health, especially mentalhealth. Based on the premise and findings of this study, theseobservations necessarily apply to practitioners of mentalsilence-orientated forms of meditation of which Sahaja Yogais an example. Taking into account the fact that two well-designed RCTs of mental silence also demonstrated signifi-cant effects on both mental and physical health parameterscompared to active controls, the association between thesubjectively reported experience of mental silence and healthobserved in this study is likely to be causal. Hence thissurvey data suggests that such approaches to meditation mayhave a potentially valuable role in primary mental healthprevention. Further research to evaluate this possibility isclearly warranted.

Future research involving comparison of mental-silence-orientated practitioners with other populations (controllingfor the exclusion of health risk factors and similar lifestylechanges as well as religious and spiritual observances) wouldbe useful to more clearly identify the source of the apparentbenefits of that this population appears to enjoy.

Acknowledgments

The authors gratefully thank the Natural Therapies Unit,Royal Hospital for Women. They thank Shanti Gosh, Dr.Gabrielle Mane, and Sandeep Mane for their assistance inrecruiting survey responses. They thank the Sahaja Yogameditators of Australia who volunteered their time andcooperated with the demands of the study without charge.The authors did not develop the meditation technique andhave no commercial interests in relation to it. They gratefullyacknowledge the developer of Sahaja Yoga meditation, ShriMataji Nirmala Devi, who encouraged this study on theproviso that the technique’s noncommercial and open-accessethos was maintained.

References

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Scientific Study of Religion, vol. 40, no. 2, pp. 323–329, 2001.[2] P. M. Barnes, E. Powell-Griner, K. McFann, and R. L. Nahin,

“Complementary and alternative medicine use among adults:United States, 2002,” Advance data, no. 343, pp. 1–19, 2004.

[3] P. Kaldor, J. Bellamy, and R. Powell, 1998 Australian Com-munity Survey. Build my Church: Trends and Possibilities forAustralian Churches, Openbook, Adelaide, Australia, 1999.

[4] J. Bellamy and K. Castle, “2001 Church attendance estimates,”NCLS Occasional Papers, National Church Life Survey, Syd-ney, Australia, 2004.

[5] M. V. Pirotta, M. M. Cohen, V. Kotsirilos, and S. J. Farish,“Complementary therapies: have they become accepted ingeneral practice?” Medical Journal of Australia, vol. 172, no. 3,pp. 105–109, 2000.

[6] P. H. Canter, “The therapeutic effects of meditation,” BritishMedical Journal, vol. 326, no. 7398, pp. 1049–1050, 2003.

[7] National Center for Complementary and AlternativeMedicine and Meditation for Health Purposes,Backgrounder: National Institutes of Health, USDepartment of Health and Human Services,http://nccam.nih.gov/health/meditation/overview.htm,2007.

[8] M. Ospina, T. Bond, M. Karkhaneh et al., “Medita-tion practices for health: state of the research,” EvidenceReport/Technology Assessment 155, Healthcare Research andQuality, Rockville, Md, USA, 2007.

[9] T. E. Seeman, L. F. Dubin, and M. Seeman, “Religios-ity/spirituality and health: a critical review of the evidence forbiological pathways,” American Psychologist, vol. 58, no. 1, pp.53–63, 2003.

[10] G. E. Fraser, “Diet as primordial prevention in seventh-dayadventists,” Preventive Medicine, vol. 29, no. 6 I, pp. S18–S23,1999.

[11] L. Otis, Ed., Adverse Effects of Transcendental Meditation, AldinPublications, New York, NY, USA, 1984.

[12] R. Manocha, “Intervention insights: meditation, mindfulnessand mind-emptiness,” Acta Neuropsychiatrica, vol. 23, no. 1,pp. 46–47, 2011.

[13] U. Rai, S. Sethi, and S. Singh, “Some effects of Sahaja Yogaand its role in the prevention of stress disorders,” Journal ofInternational Medical Sciences, pp. 19–23, 1988.

[14] R. Manocha, G. B. Marks, P. Kenchington, D. Peters, and C.M. Salome, “Sahaja Yoga in the management of moderate tosevere asthma: a randomised controlled trial,” Thorax, vol. 57,no. 2, pp. 110–115, 2002.

[15] R. Manocha, D. Black, J. Sarris, and C. Stough, “A random-ized, controlled trial of meditation for work stress, anxietyand depressed mood in full-time workers,” Evidence-BasedComplementary and Alternative Medicine, vol. 2011, Article ID960583, 8 pages, 2011.

[16] V. K. Sharma, S. Das, S. Mondal, U. Goswami, and A. Gandhi,“Effect of Sahaja Yoga on neuro cognitive functions in patientssuffering from major depression,” Indian Journal of Physiologyand Pharmacology, vol. 50, no. 4, pp. 375–383, 2006.

[17] D. Morgan, “Sahaja Yoga: an ancient path to modern mentalhealth?” Transpersonal Psychology Review, vol. 4, no. 4, pp. 41–49, 2001.

[18] L. J. Harrison, R. Manocha, and K. Rubia, “Sahaja YogaMeditation as a family treatment programme for childrenwith attention deficit-hyperactivity disorder,” Clinical ChildPsychology and Psychiatry, vol. 9, no. 4, pp. 479–497, 2004.

[19] R. Manocha, B. Semmar, and D. Black, “A pilot study of a men-tal silence form of meditation for women in perimenopause,”Journal of Clinical Psychology in Medical Settings, vol. 14, no. 3,

pp. 266–273, 2007.[20] U. Panjwani, W. Selvamurthy, S. H. Singh, H. L. Gupta, L.

Thakur, and U. C. Rai, “Effect of Sahaja Yoga practice onseizure control & EEG changes in patients of epilepsy,” IndianJournal of Medical Research, vol. 103, pp. 165–172, 1996.

[21] J. Ware, M. Kosinski, and S. Keller, SF-36 Physical and MentalHealth Summary Scales: A User’s Manual, Health AssessmentLab, Boston, Mass, USA, 1994.

[22] L. K. George, C. G. Ellison, and D. B. Larson, “Explainingthe relationships between religious involvement and health,”Psychological Inquiry, vol. 13, no. 3, pp. 190–200, 2002.

[23] G. Feuerstein, “Yogic meditation,” in The Experience ofMeditation: ExpertsIntroduce the Major Traditions, J. Shear,Ed., pp. 87–117, Paragon House, St. Paul, Minn, USA, 2006.

[24] R. Manocha, D. Black, J. Ryan, C. Stough, and D. Spiro,“Changing definitions of meditation: physiological corollo-rary,” Journal of the International Society of Life Sciences, vol.28, no. 1, 2010.

[25] C. Carlson, P. Bacaseta, and D. Simanton, “A controlled eval-uation of devotional meditation and progressive relaxation,”Journal of Psychological Theory, vol. 16, no. 4, pp. 362–368,1988.

[26] L. I. Aftanas and S. A. Golocheikine, “Human anterior andfrontal midline theta and lower alpha reflect emotionallypositive state and internalized attention: high-resolution EEGinvestigation of meditation,” Neuroscience Letters, vol. 310, no.1, pp. 57–60, 2001.

[27] L. Aftanas and S. Golosheykin, “Impact of regular meditationpractice on EEG activity at rest and during evoked negativeemotions,” International Journal of Neuroscience, vol. 115, no.6, pp. 893–909, 2005.

[28] S. W. Lazar, C. E. Kerr, R. H. Wasserman et al., “Meditationexperience is associated with increased cortical thickness,”NeuroReport, vol. 16, no. 17, pp. 1893–1897, 2005.

[29] K. Rubia, “The neurobiology of Meditation and its clinicaleffectiveness in psychiatric disorders,” Biological Psychology,vol. 82, no. 1, pp. 1–11, 2009.

http://nccam.nih.gov/health/meditation/overview.htm

At the Royal Hospital for Women in Sydney, a Meditation Research Program has been in progress, under

Ramesh Manocha in the hospital’s Natural Therapies Unit. Using the sahaja yoga technique of meditation,

the research has shown promising results for the treatment of asthma, headache, menopause and depression.

Australian Complementary Health AssociationDiversity Vol. 2 No.5 june 2001

F E A T U R E2

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3F E A T U R E

Australian Complementary Health Association Diversity Vol. 2 No.5 june 2001

Dr Ramesh Manocha graduated in

medicine from the University of New

South Wales. After a number of years

in clinical practice he became

interested in the clinical applications

of meditation. He is now Barry Wren

Fellow at the Royal Hospital for

Women, Sydney, where he initiated

the Meditation Research Program.

The ancient tradition of yoga and meditation

began in Indian prehistory as a system of mental,

physical and spiritual exercises. In approximately

500BC the physician and sage Patanjali formalised this

tradition into a science with four major and four lesser

branches involving ethical restraint, self-discipline,

mental focus, physical exercise and meditation. The

entire system was used in an integrated fashion and

directed at the attainment of a unique state of

spontaneous, psychological integration.1 Modern

psychologists have described this state as

“individuation”2 or “self-actualization”3 and it has been

traditionally termed “self-realisation”.

Many studies of meditation and yoga have been

conducted over the past 50 years with variable results.4

The advent of Transcendental Meditation in the 1960s

and 1970s gave scientists an opportunity to study a

standardised technique. Many interesting results were

obtained in multifaceted studies; however problems

with methodology and interpretation of data have been

noted.5 Similarly, other techniques have been assessed

giving results which are often remarkable but,

unfortunately, inconsistent and difficult to reproduce.

The cultic connotations of many of these techniques and

the organisations that promote them are also of

considerable and justifiable concern and have, no

doubt, hampered research in this area.6

Yet the health practitioner continues to intuitively

recognise the role of stress in clinical illness,

particularly in relation to the so-called

“psychosomatic” diseases.7

Despite the tremendous advances in modern

medicine we are still to develop truly effective strategies

to deal with the common public health problems that

cause most of the mortality and morbidity in the wider

community. The use of stress reduction has been shown

to be beneficial in many diseases, as it improves

psychological and physical health and lifestyle

awareness.8 Importantly the utilisation of stress-

reducing techniques brings us closer to the ideal of a

holistic, integrated health care strategy.

Several mechanisms have been proposed to

ResearchingmeditationClinical applications in healthcare

by ramesh manocha

An earlier version of this article was presented as a paper at the Sixth

International Holistic Health Conference at Lorne, Victoria, in March 1999.

DiversityVol. 2, No. 5 June 2001

natural & complementary health

published in

magazine

explain the way in which psychological stress translates

into physical disease. Some of the mystery has been

explained by the “general adaptation syndrome” in which

stressors induce psycho-hormonal changes. In an acute

context these changes result in emergency adaptation of

physiological function. In a context of chronic

stimulation these changes, rather than maintaining

psychological homeostasis, ultimately result in physical

debilitation of body systems.9 The “parasympathetic

response”, or “relaxation response”, is another

mechanism worthy of investigation.10 It is the

physiological opposite to that of the “fight or flight”

reaction that we are all familiar with. It involves a slowing

of the heart rate, reduced rate of respiration and

relaxation of the muscles, in association with a reduction

in circulating stress hormones and alpha brain wave

activity. This physiological reaction is mediated by the

autonomic nervous system, a complex set of nerves that

governs all the automatic systems of the body that are

essential for life. The role of the hypothalamic pituitary

axis, which is the main controlling centre for the

hormonal activities of the body, is also worth considering.

Regardless of the underlying theories, the

majority of clinicians recognise that stress is a major

contributor to disease and that a simple stress

management technique, such as meditation - once

scientifically proven and clinically evaluated - could

be widely applied in the clinical setting.

SAHAJA YOGA

About fifteen years ago in India, Professor U.C. Rai

accomplished some pioneering work with a technique of

meditation called sahaja yoga. He was head of the

Department of Physiology at Maulana Azad Medical

College in Delhi. He himself had suffered serious angina

attacks and was surprised to find that this technique of

meditation seemed to alleviate his medical condition.

Professor Rai, impressed by this personal

experience, sought to scientifically document the effects

of this technique. He set up a multifaceted research

project. Part of this was a study on the effects of sahaja

yoga meditation on chronic illnesses such as epilepsy and

asthma. Rai’s research team found that regular practice of

this technique reduced the frequency, severity and

duration of his patients’ epileptic seizures.11 Moreover,

when Rai taught another group a mimicking exercise,

which resembled but was actually not the real technique,

the same improvement did not occur!12

Some years later, we, a handful of health workers

in Sydney, came across Rai’s work. The results that he

had achieved in conditions ranging from asthma to

high blood pressure were very encouraging so we

decided to test this technique under scientific

conditions here in Australia. This was the beginning of

the Meditation Research Program.

Our first goal was achieved when we established the

Mind-Body Meditation Clinic. This was a non-profit

service that offered instruction in meditation to patients

looking for a more holistic approach to the treatment of

their condition. A wide variety of patients were sent to us

with many different problems; most of them chronic

conditions for which there was little to offer within the

mainstream of medicine. Within a few sessions of

instruction most patients reported improvements. Some

of the toughest cases, to our amazement, remitted

completely with diligent practice of the technique.

So when “Andrew” arrived in our clinic one day, we

were not unaccustomed to challenges. Andrew was a

young man of about twenty years of age when his mother

brought him to the meditation clinic at Blacktown, a

working class suburb in Sydney’s outer west.

Two years before this, he had contracted

encephalitis, a viral infection of his brain tissue which

put him in hospital for several weeks; his condition so

critical at one stage that he was transferred into the

intensive care unit. Although Andrew did survive, the

viral attack on his brain had left subtle scars on this

most sensitive of organs. It caused the neurons to

“short circuit” and produce overpowering waves of

electrical signals that spread across his entire brain.

This “brainstorm” resulted in severe epileptic

seizures. While the viral infection of Andrew’s brain

was over, it had left behind permanent damage which

condemned him to a life of violent epilepsy.

Epilepsy is a well recognised complication of

brain infection. In this case it had taken a promising

and talented student and turned him into an invalid.

Andrew’s fits were so frequent - sometimes up to two

or three times per day - that he could neither resume

his schooling nor keep a job. He was dependent on his

parents for everything, and so their lives had also

become considerably restricted by their son’s illness.

As with the other patients in the Mind-Body

Meditation Clinic, we advised Andrew that his

response to the technique would mostly be

R E S E A R C H I N G M E D I T A T I O N

Diversity Vol. 2 No.5 june 2001 Australian Complementary Health Association

4

Brainwaves from a meditator as displayed on a computer screen.

ANDREW: TAMING THE BRAINSTORM



5

It so happened that Professor Rai had also looked

at the effect of meditation on asthma during his

investigation into the sahaja yoga effect. So we decided

to use his results along with our accumulated

experience at the meditation clinic as a basis for an

asthma trial here in Australia.

In consultation with a number of respected asthma

researchers a strategy was devised to compare the effect

of meditation against a simple relaxation technique. We

wanted to know whether there really was something

unique about this process or if it was simply like any

other relaxation technique. Our plan involved selecting

a large group of people with severe asthma whose

condition did not properly respond even to maximum

levels of medication. These people were divided into

two groups. One group received regular instruction in

sahaja yoga meditation while the other group was taught

a popular relaxation technique. Before, and then after,

about 16 sessions, the patients were assessed and the

two groups compared to see if there was a difference

between the two techniques. The Royal Australian

College of General Practitioners funded the project and

after 18 months it was completed.

The results were surprising! Most of us expected

to see no difference at all between the relaxation and

meditation groups. Yet the results clearly showed that

while both groups did appear to bring about

improvements in the way the patients felt, the

meditation also showed improvements in the severity

of the disease process itself! This effect was not seen at

all in the relaxation group and it suggested that

meditation can actually influence the disease process.

DAVID: A BREATH OF FRESH AIR

There were many remarkable individual stories

within the Asthma project. One of them is “David’s”. A

typical 42 year old “Aussie battler”, he had suffered

asthma since infancy, which had greatly frustrated

both his career and his sporting ambitions. When we

assessed him prior to his entry to the trial his asthma

determined by his own motivation to meditate

regularly. We were not the healers in the clinic, rather

Andrew was going to learn how to awaken an innate

and spontaneous healing power within himself. This

energy would work inexorably through his meditation

to improve his physical, mental and spiritual health.

Professor Rai’s epilepsy research showed that

patients who practised the technique consistently

experienced reductions in the amount and severity of the

fits that they were experiencing. This gave us confidence

that Andrew could use this technique to his benefit.

Andrew learned the sahaja yoga technique quickly

and practiced it diligently. The first changes we noticed

were in Andrew‘s face: his eyes lost their usual dullness;

they looked clear and bright. When we first saw this 19

year old boy he looked like an old man: hunched over,

drawn face and dark rings under his eyes. Now he started

to look young again and the dark shadow that seemed to

hang over him had gone. After a few weeks he would even

come to the class with a smile where usually there was

only a frown. Andrew’s progress was obvious to us and it

was not too much of a surprise to hear from his parents

that his fits were reducing in frequency.

After several weeks his mother came to the clinic to

invite us home for dinner. Andrew had not had a major fit

in four weeks, they were planning to go away for the

weekend and for the first time in many years life was

starting to look normal for them!

ASTHMA RESEARCH

Successful cases like Andrew’s and many of the other

patients were inspiring for us all, but single case

histories, no matter how remarkable, do not constitute

scientific proof. The medical science establishment

demands a standard of scientific rigour in order to

establish the authenticity of any new form of treatment.

So after more than two years of the meditation clinic we

had enough confidence and had gathered sufficient

evidence to embark on a proper attempt to scientifically

evaluate the sahaja yoga technique.

A study of sahaja yoga meditators using

a Quantitative Electro Encephalo Gram,

demonstrated widespread changes in

brainwaves, with prominent theta wave

activity at the precise moment that the

meditators reported a state of complete

mental silence and “oneness”.

Participant in the Meditation Research Program, with a QEEG headcap designed to pick up electrical signals produced by the brain, and thusmonitor changes in brainwave activity during meditation.

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saved more than $1,500 in medication expenses since he

started the program!

HOT FLUSHES

Hot flushes are a common problem amongst

women in their menopausal years. In fact 90% of

women can expect to experience menopausal

symptoms of which the hot flush is the most common.

It is an experience characterised by flushing of

the skin of the upper part of the body, sweating,

a sensation of heat and associated feelings

of unwellness.

Interestingly, the hot flush can be worsened or

brought on by stress. In fact many women report that

high-pressure situations greatly worsen the number

and severity of the flushes that they experience. Also,

women report that their flushes improve somewhat

when they are calm and relaxed.

With this in mind we set up a pilot trial of hot flushes

for menopausal women. Ten women were enrolled into

an eight-week program. The frequency and severity of

their hot flushes and other menopausal symptoms were

recorded using standard methods before and after the 8

week program. The results were very impressive with all

women experiencing improvement in their condition. In

fact 9 out of the 10 women reported at least 50%

reductions in the frequency of their hot flushes. Six of

these women had a 65-70% improvement in their hot

flushes which, after eight weeks of meditation

“treatment”, is comparable to that seen in conventional

was in the severest of categories. Simply blowing into

the spirometer, a machine used to test lung capacity,

caused his asthma to worsen! After sixteen weeks of

meditation, which he took to like fish to water, he

returned for reassessment.

At the lung function laboratory we saw a changed

man. David’s lung function had increased, his symptoms

reduced massively and the standard tests that initially

placed him in the severest of asthma categories now

indicated that his asthma was one of the mildest! David

told us that his asthma had improved so much that he was

sleeping through the night rather than being woken with

symptoms; that he was playing sport; and that he had

6

“What a great thing it would be if we in

our busy lives could restore into ourselves

each day for at least a couple of hours and

prepare our minds to listen to the voice of

the great silence. The divine radio is always

singing if we could only make ourselves ready

to listen to it, but it is impossible to listen

without silence.” Mahatma Gandhi

Sequence showing a group of meditators sitting with the founder of the sahaja yoga meditation technique, Shri Mataji Nirmala Devi. The photographs appear torecord rays of light eminating from the meditators, not visible to the naked eye. This may represent an increased radiation of subtle energy during meditation.



7

hormone replacement therapy! In addition, standard

measures of quality of life and symptom profiles showed

similar degrees of improvement.

We are now planning a larger, randomised,

controlled trial to more conclusively determine the

potential for meditation in this troublesome problem.

HOW DOES IT WORK?

How does meditation bring about these effects? The

“sahaja yoga hypothesis” is that meditation triggers a

process within the autonomic nervous system, a complex

set of nerves that governs the function of all the organs of

our body. Imbalance within this system, says the

hypothesis, is the cause of both physical and

psychological illness. The process of meditation

rebalances this system thereby allowing our natural

healing processes to revitalise and rejuvenate

diseased organs.

The ancient yoga tradition explains the inner healing

process in terms of seven subtle energy centres (called

“chakras”) that exist within our body. Each of these

centres governs a specific set of organs, and aspects of our

psychology and spirituality. Imbalanced function of these

centres results in abnormal function of any aspect of our

being (physical, mental or spiritual) that relates to the

imbalanced centre.

Meditation is said to be a specific process that

involves the awakening of an innate, nurturing energy

called “kundalini”. The awakening of the kundalini

causes it to rise from its position in the sacrum bone and

pierce through each of the chakras, causing each of them

to come into a state of balance and alignment (like a

string threading through a series of beads). In this way

the chakras are rejuvenated and nourished by the

kundalini’s ascent. As the kundalini reaches the brain

and the chakras within it, mental tensions are

neutralised. An inner state of mental calm is established.

This inner silence becomes a source of inner peace that

neutralises the stresses of daily life, enhancing creativity,

productivity and self-satisfaction.

BRAIN WAVES

In order to try and understand what it is about

meditation that makes it special we have turned to some

sophisticated brain imaging technology. A pilot study of

advanced sahaja yoga meditators using a QEEG

(quantitative electro encephelo gram) has yielded some

very interesting results. This method is able to produce

two-dimensional maps of the electrical changes in the

brain as the meditator enters into the state of

meditation. Our study was conducted on a small group

of meditators who were each asked to meditate while

wearing a QEEG headcap designed to pick up the tiny

electrical signals produced by the brain.

They were instructed to sit quietly for some time,

then to commence meditation and signal when they

had definitely entered into the meditative state called

“thoughtless awareness”. The findings were

fascinating: all three of the meditators displayed

widespread changes in brainwave activity that became

more intense as they meditated.

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Widespread, intense “alpha wave” activity occurred

initially. Alpha wave activity is associated with relaxation

and is thought to be a beneficial state. In fact alpha

activity has been observed in a number of different forms

of meditation. The remarkable thing, however, is that as

the meditators signalled that they had entered into the

state of mental silence, or “thoughtless awareness”,

another form of brain wave activity emerged which

involved “theta waves” focused specifically in the front

and top of the brain in the midline.

Precisely at the time that the theta activity became

prominent, the meditators reported that they

experienced a state of complete mental silence and

“oneness” with the present moment, a state which

characterises the sahaja yoga meditative experience.

There are several remarkable features about this

pilot study which warrant further investigation.

First, very few meditation techniques have shown

this kind of consistent change in the theta range

suggesting that the technique may have a unique effect

on the brain. We were only able to find one other

study, out of several dozen published in the scientific

literature, that showed changes of this nature. This

study involved a group of Japanese Zen monks.

Practitioners of sahaja yoga often claim to feel the

chakras (energy centres) within the head open up as the

meditative experience intensifies. They assert that it is

this experience which is the essence of true meditation

and that very few other meditation techniques enable

the subject to repeatedly access this experience. The

fact that the theta activity is relatively unusual and that it

was observed in coincidence with the meditators’

reported experience does suggest that there may be

something unique and authentic about the sahaja yoga

method and its claims.

Second, it is very significant that the changes

observed in the brain images occurred at the moment

that the meditators reported experiencing the

meditative state. This suggests that the QEEG method

may make it possible to directly study mystical states

of consciousness! The fact that these changes occurred

within minutes rather than hours or longer suggests a

relatively effortless or spontaneous process (as

suggested by the name of the technique - “sahaja” is

8

Sanskrit for “effortless”).

Third, the focus of theta activity at the front of the

head and top of the head, both in the midline, suggest that

structures deep within the brain, possibly the limbic

system, are being activated. The limbic system is

responsible for many aspects of our subjective

experiences, such as emotion and mood, so it is no

surprise that meditation, which is traditionally associated

with blissful states, might involve this part of the brain.

Finally, in speculation, the two areas of theta

activity coincidentally correspond to the two main

chakras in the brain, according to yogic tradition. The

forehead chakra called “agnya” or “third eye” is located

in the centre of the forehead while the chakra at the top

of the head, is called “sahasrara” or “crown chakra” and

is traditionally associated with the limbic system.

VIBRATIONAL ENERGY

Many practitioners in the complementary health

field subscribe to the idea of “vibrational medicine”. This

idea essentially suggests that complementary therapies

such as homoeopathy and therapeutic touch, as well as

other therapeutic phenomena such as the placebo effect,

therapeutic contact, bedside manner, and spiritual

healing, act on a subtle energetic level to achieve cure or

promote wellness. The difficulty has been that we are

unable to detect this “subtle energy” and so scientific

verification of this concept is difficult to achieve.

However Kirlian photography, new research technology

such as SQUID (“superconducting quantum interference

device”), and aura imaging all offer clues to the puzzle.

The yogic explanation is simple: all therapeutic

modalities act in one way or another on the subtle system

of chakras and kundalini. This idea is difficult to directly

verify but while doing background work and interviews

for our research program a number of sahaja yoga

practitioners described unusual sets of photographs that

had been taken of sahaja yoga meditators. There appeared

to be a wide variety of these photographs displaying, for

the most part, rays and streaks of light around people.

One series of photographs, which included a group of

meditators sitting with the founder of the sahaja yoga

meditation technique, Shri Mataji Nirmala Devi, was

JAPA

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Meditation at a Zen Buddhist temple in Japan (above) and at the Buoyancy Foundation in Melbourne (right). Zen meditation andsahaja yoga meditation are the only two types of meditation which have demonstrated prominent theta brainwave activity.

AN

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9R E S E A R C H I N G M E D I T A T I O N


particularly interesting. It consisted of a series of

photographs in which the “vibrational energy” emitted by

the individuals was recorded in the photographs,

progressively becoming more intense with each

photograph. Remarkably, these photographs were

allegedly taken well before the age of digital photography.

Of even greater interest was that the people who owned

this fascinating evidence were not particularly fussed as

to whether or not it should be publicised. When I

expressed my surprise at their apparent diffidence, they

replied that photographic evidence was irrelevant to

them as the primary goal of their technique was personal

meditative experience rather than the collection of

physical artefacts - no matter how remarkable.

THE EASTERN VIEW OF STRESS

Meditation is an eastern tool that offers western

health practitioners a new way of looking at health. The

role of stress in disease is well recognised by modern

medical researchers but, despite the progress that has

been made in this field, there remains some very

fundamental yet unanswered questions. One of those

question is, “What exactly is stress?”. Few of us can easily

come up with a good definition of “stress”, yet while we

don’t know exactly what it is, we intuitively recognise that

it is a factor that affects almost every aspect of our lives!

The eastern explanation of “stress” is probably one

of the most commonsense and practically useful ones.

While you read this see if you can “look inside” and apply

this perspective to yourself. Stress, says the eastern

perspective, is the by-product of thought. If we examine

the nature of the thoughts that each of us experiences

from moment to moment we will find that they all relate

to one of two broad categories: (l) events that have

occurred in the past or (2) events that we anticipate will

occur in the future. Whether the event was an argument

with a friend yesterday (past), an unpaid bill (future), a

deeply troubling childhood experience that has become

part of our subconscious (past) or anxiety about the share

market (future) we will find that all of these troubling

thoughts, and the resulting stress that they cause us, to

have arisen from only the past or future!

Take the exercise a little further. If the vast

majority, if not all, our thoughts emanate from events

in the past or future, is it possible to think about the

absolute present moment? Most of us will admit that,

while we can think about events in the past (even a few

moments ago), or events scheduled in the future (even

milliseconds in the future), it is impossible to actually

think about the present moment which we are

continuously experiencing and is ever changing.

Now think about the stress that we all experience

from time to time. Despite the huge variety of situations

that “stress” us they all have one thing in common: we

have to think about the events before they can reduce our

sense of wellbeing. In other words thought itself is the

final common pathway by which all events create stress

within us!

The past, comprised of events that have already

occurred, no longer exists. Similarly the future,

comprised of events that have yet to occur and are

therefore undetermined, does not yet exist. However,

paradoxically, we human beings exist only in the present.

The mind (and its thoughts), since it is comprised only of

stuff from the past or future, is therefore not real and so

the stress that it generates is also not real!

If we are beings that exist in the present, and we

realise that the stress and angst of life emanate from a

mind which is the product of past/future, we

acknowledge also that the antidote for the mental

illusions that cause stress is to reign in our attention

and focus it on the present moment.

In a trial of sahaja meditation, 9 out of 10

menopausal women reported at least 50%

reduction in frequency of their hot flushes,

and the overall improvement in their

condition was comparable to that seen in

hormone replacement therapy

10 R E S E A R C H I N G M E D I T A T I O N


While, for most of us, focusing on the absolute

present moment is virtually impossible, it is this razor’s

edge of “thoughtless awareness” that the easterner

seeks to cultivate and sustain in meditation. The vast

inner silence of the thoughtless state leaves the mind

uncluttered. By existing in that “space-between-the-

thoughts” one is neither enslaved to one’s past nor

confined to a predetermined future. The inner silence

of meditation thus creates a naturally stress-free

inner environment.

LIVING IN THE MOMENT

Is it possible for humans to live in the present

moment? Yes, it is, and most of us encounter living

examples of it regularly!

Observe closely the next small child you encounter.

They have no worried lines on their faces, are almost

always playing and enjoying themselves, and rarely

complain about bills, jobs, chores, etc. If one happens to

have an unpleasant experience it is quickly forgotten and

life goes on. They are naturally balanced, living-in-the-

present, stress-free beings. Who has seen a toddler hold

a grudge, worry about the next meal or even think about

what they did yesterday or will do tomorrow? They are so

focused on the present moment that they are entirely

spontaneous, unpretentious and usually very happy. They

are in a constant state of effortless meditation.

Living in the moment is not, however, a

regression to immaturity. It is an evolutionary step in

which we return to our childlike innocence and

simplicity but in full awareness of ourselves, our place

in society and our moral role and responsibility.

How does one tap into and sustain a connection

with the present moment? How does one escape the

brainstorm of mental stress that we all experience?

We would all agree that more research needs to be

done to try to understand how the “sahaja yoga effect“

occurs. Does it work via the autonomic nervous system?

Is it really the result of an energy that exists within each of

us called kundalini? Is it possible to examine the most

ancient of traditions with modern science? The

Meditation Research Program at the Royal Hospital for

Women will continue to delve into these important

questions.13 Suffice to say for now that sahaja yoga

meditation appears to offer a method by which each of us

can tame the brainstorm, realise a state of peace and

tranquillity and begin to heal our body, mind and spirit.

Meditation Research Programme, The Natural Therapies

Unit, Royal Hospital for Women, Ph (02) 9382 6626, Fax (02)

9382 6660. Email: [email protected]

References

1. Neki, J.S., “Sahaja: an Indian ideal of mental health”, Psychiatry,

Vol. 38, No. 1, Feb 1975, pp. 1-10.

2. Van der Post, L, Jung and the Story of Our Time, Penguin, 1975.

3. Maslow, A., Religions, Values, and Peak Experiences, The Viking Press,

New York, 1972.

4. Holmes, D.S., “The influence of meditation, versus rest, on

physiological arousal”, in West, M.A., (ed.), The Psychology of

Meditation, Clarendon Press, Oxford, 1987.

5. ibid.

6. Skolnick, A.A., “Maharishi Ayur-Veda: Guru’s marketing scheme

promises the world eternal ‘perfect health’ ”, Journal of the American Medical

Association, Vol. 266, No. 13, 2 Oct 1991, pp. 1741-2, 1744-5, 1749-50.

7. Bridges-Webb, C., Britt, H., Miles, D.A., Neary, S., et al, “Morbidity and

treatment in general practice in Australia”, Australian Family Physician, Vol.

22, No. 3, March 1993, pp. 336-9, 342-6; Cohen, S., Tyrrell, D.A., Smith,

A.P., “Psychological stress and susceptibility to the common cold”, New

England Journal of Medicine, Vol. 325, No. 9, 29 August 1991, pp. 606-12.

8. Fawzy, F.I., Fawzy, N.W., Hyun, C.S., Elashoff, R., et al., “Malignant

melanoma: Effects of an early structured psychiatric intervention, coping,

and affective state on recurrence and survival 6 years later”, Archives of General

Psychiatry, Vol. 50, No. 9, 1993, pp. 681-9; Spiegel, D., Bloom, J.R., Kraemer,

H.C., Gottheil, E., “Effect of psychosocial treatment on survival of patients

with metastatic breast cancer”, The Lancet, Vol. 2, No. 8668, 1989, pp. 888-91.

9. Benson, H., The Relaxation Response, Avon, New York, 1976.

10. Rai, U.C. et al., “Some effects of Sahaja Yoga and its role in the prevention

of stress disorders”, Journal International Medical Sciences Academy, 1988.

11. Panjwani, U., Selvamurthy, W., Singh, S.H., Gupta, H.L.,

Mukhopadhyay, S., Thakur, L., “Effect of Sahaja yoga meditation on auditory

evoked potentials (AEP) and visual contrast sensitivity (VCS) in epileptics”,

Applied Psychophysiology & Biofeedback, Vol. 25, No. 1, March 2000, pp. 1-12.

12. Rai, op. cit. (Ref 9).

13. Manocha, R., “Why Meditation?”, Australian Family Physician,

Vol. 29, No. 12, Dec 2000. pp. 1135-1138.

research

454 australian Family Physician Vol. 38, No. 6, June 2009

a recent survey found that 60% of general practitioners wanted educational material to help in the management of stress, and that 28% of those seeking education were experiencing significant levels of stress.1

A national survey of Australian GPs found that work was the major stressor in GPs’ lives. One in eight (12.8%) GPs surveyed had scores indicative of severe psychiatric disturbance. Fifty percent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress. Those who had considered leaving their current workplace or careers were also more likely to be moderately or severely stressed.2

Concerning the issue of stress in the medical profession, Riley states: ‘The issues of health and wellbeing of doctors – self care, stress management and so on – should be... kept on the agenda in continuing professional development programs’. He goes on: ‘We must be better prepared as individuals and as organisations to respond to the early signs of distress... accordingly, relevant professional organisations need to devise and become familiar with pathways for responding’.3

Stress management interventions such as meditation have been identified as simple yet potentially effective health promotional strategies that can make a significant contribution to improving general health, beyond that of simply addressing the immediate impact of work stress.4 Meditation is a particularly important stress management skill because, once taught, it can be practised independently, and at will, to both reduce acute stress and serve as a buffer against ongoing and chronic stress.5

Meditation is widely perceived as an effective method of reducing stress and enhancing wellbeing. In Australia, a survey of the general community (n=1033) found that 11% of respondents had practised meditation at least once.6 The Australian community survey found that 29% of Australians found prayer to be a source of peace and wellbeing, while 24% used meditation for the same

Deborah Black BSc, DipEd, MSTAT, PhD, is a biostatistician, Health Informatics and Statistics Faculty, Faculty of Health Sciences, University of Sydney, New South Wales.

Gin malhi MBChB, BSc(Hons), FRANZCP, FRCPsych, MD, is Head, Discipline of Psychological Medicine and Executive Director, ARCHI, Northern Clinical School, University of Sydney, and Director, CADE Clinic, Royal North Shore Hospital, Sydney, New South Wales.

amy Gordon is a medical student, School of Medicine, University of Glasgow, United Kingdom.

ramesh manocha MBBS, BSc(Med), PhD, is a general practitioner and Research Fellow, Natural Therapies Unit, Royal Hospital for Women, Sydney, New South Wales. [email protected]

using meditation for less stress and better wellbeingA seminar for GPs

BackgroundGeneral practitioner stress is a recognised problem for which meditation is a potential intervention. The aim of this project was to evaluate the feasibility, acceptability and effectiveness of an initiative to train GPs in a set of evidence based meditation skills.

methodGeneral practitioners attended a seminar comprising a 1 hour lecture on GP wellbeing, a 45 minute session on meditation, meditation skills practise in groups with an experienced instructor, a larger group review and the provision of take home kits. At the seminar’s conclusion, GPs were offered the option of meditating at home twice daily. Measures were taken before and after the seminar and after 2 weeks home practise. The measures included the Kessler Psychological Distress Scale – 10 (K10), personal experience rating by visual analogue scale, and diary card.

resultsA total of 299 GPs attended the seminar, from which 293 provided visual analogue scale on the day. Pre- and post-K10 data was provided by 111 GPs. The mean pre-K10 score for these GPs was 17.2 (SD: 5.67); the post-K10 score was 14.7 (SD: 3.92), with 25.1% of the ‘at risk’ participants moving to the ‘low risk’ category. Mean compliance with meditation was 79.5%.

DiscussionA meditation workshop for GP wellbeing is practical, feasible and appealing to GPs. Quantitative feedback from the workshop indicates its potential as an effective mental health promotion and prevention strategy.

June_research_manocha.indd 454 21/5/09 12:05:04 PM

AustrAliAn FAmily PhysiciAn Vol. 38, No. 6, June 2009 455

purpose.7,8 Interestingly, Kaldor reports some psychophysiological differences between prayer and meditation,6 while Benson has suggested that meditation can be practised without need for change in religious affiliation.9

Health professionals are also enthusiastic about meditation, despite a lack of formal education about it. A survey of Australian GPs in 2000 found that almost 80% of respondents had recommended meditation to patients at some time in the course of their practice, despite the fact that only approximately 30% had had any type of education about it.10 A more recent formal survey by Cohen et al11 in 2005 found that 56% of GPs would like to receive some form of training in meditation skills.11

It is unclear however, whether or not such a meditation based resource, when implemented in the ‘real world’, would be feasible or effective for GPs as a stress reducing, wellbeing enhancing strategy. The aim of this project was to evaluate the feasibility, acceptability and effectiveness of an initiative to train GPs in a set of evidence based meditation skills. The project was based on the findings of the Meditation Research Programme (MRP) at the Natural Therapies Unit of the Royal Hospital for Women in Sydney.12 The MRP has been involved in the systematic evaluation of a ‘mental silence’ orientated form of meditation and subsequent development of delivery strategies for consumers, patients and professionals since 1998. A rigorous randomised trial of this approach, when compared to an active control, demonstrated significant effects on measures of work related stress, anxiety and depression.13 Other trials of the same approach have demonstrated promising effects in depression/anxiety,14 asthma15 and epilepsy.16,17 The technique evaluated by the MRP is called ‘Sahaja yoga’ and it is typified by the experience of mental silence.12

methodThe seminar was advertised broadly to the GP community through a brochure distributed via medical newspapers and direct mail. It comprised a 1 hour lecture on GP wellbeing issues followed by a 45 minute lecture on meditation and its potential benefits. This was followed by a guided meditation session for the entire group. Delegates then broke up into smaller groups of approximately 25–30 to revise and expand the skills they had learnt, with the aim of enhancing the mental silence experience. Each group was facilitated by an experienced meditation instructor. After the workshops, participants reassembled in the auditorium for a further meditation session, which was followed by concluding comments and questions. Each participant was given a home practise kit which included a

meditation CD (developed as part of the MRP’s clinical trials), an instruction card, a diary, the K10 questionnaire and a candle. Participants had the option of undertaking further structured home practise consisting of twice daily meditation for 2 weeks, which they would record on the diary card. Participation in the seminar alone qualified GPs for Category 2 CPD points; the 2 week home practise tasks (based on diary card and post-task questionnaires) were considered an active learning module (ALM) and qualified participants for Category 1 CPD points.

measures

Kessler 10 Psychological Distress scaleThe Kessler Psychological Distress Scale – 10 (K10) questionnaire was completed at the beginning of the seminar (the ‘before’ assessment) and at the end of the 2 week home practise session (the ‘after’ assessment). Consisting of 10 questions that appraise psychological distress, the K10 questionnaire has been used in a number of population health surveys in Australia.18,19 The National Health and Wellbeing survey in 2001 used the K10 as a measurement tool to identify segments of the population at risk of developing mental illness. The categories are based on work by Andrews and Slade19 and comprise ‘low’, ‘moderate’, ‘high’ and ‘very high’. The last category represents the portion of the population previously found to meet diagnostic criteria for clinical depression and anxiety requiring professional help.

Personal experience rating by visual analogue scale

At the end of the seminar, participants rated the degree to which their experience of ‘mental activity’, ‘calm and peacefulness’ and ‘stress tension’ had changed compared to usual, using a specifically developed visual analogue scale (VAS).

the rAcGP learning objectives survey

A compulsory part of the continuing professional development (CPD) process, The Royal Australian College of General Practitioners (RACGP) learning objectives survey provides feedback on participant perceptions of the educational effectiveness of the initiative.

Diary card

Using a diary card, participants indicated how often they were meditating. They also rated their experience of mental silence on a scale where 0 represented their usual level of thinking and 10 complete inner silence.

resultsParticipation and response rates are summarised in Table 1.

K10 scores

Using the same standardised risk categories described above, 46.2% of the GP sample was in the low risk (ie. normal) category. Australian population norms show 64.3% of people in this category20 – a statistically significant difference (p<0.01).

raymond seidler MBBS, FAChAM, RACP, is Medical Director, Eastern Sydney Division of General Practice, and a specialist in addiction medicine.


RESEARCH

AuStRAliAn FAmily PHySiCiAn Vol. 38, No. 6, June 2009 457

using meditation for less stress and better wellbeing – a seminar for GPs

the intervention was successful in targeting those GPs who needed assistance. The substantial change in the number of GPs in the at risk categories at the end of the initiative is clinically significant, suggesting that the intervention has practical potential. The correlations between K10 scores and self rated mental silence provide some support for the notion that mental silence is of specific importance to the beneficial effects of the seminar. Both the personal experience ratings and the learning objectives survey indicate that the experience was constructive and perceived as successful in upskilling and educating GPs on how meditation may be useful. This study, along with the other published studies, demonstrates that regular meditation can empower participants to pursue and maintain higher levels of wellbeing. Therefore, meditation has considerable potential both as a mental health promotion strategy and as a primary prevention strategy for those identified as suffering from mild to moderate psychological distress and who are therefore at risk of further deterioration. Logically, the potential benefits of this type of initiative are relevant to all health professionals. In fact, GPs’ patients may well be a reasonable target for interventions such as this. Overseas studies estimate that up to 40% of patients presenting to GPs are psychologically distressed.21–23 The majority (50–70%) of general practice consultations feature stress related issues,24 which makes medical practitioners, and especially GPs, the first point of contact for most people who are psychologically distressed.25–28 Cohen’s 2005 survey11 reported that if the topic of meditation is raised by a patient, 65% of GPs would actively encourage them to pursue it. The survey also reported that 9% of

Of the GPs who attended the seminar, 111 completed the home based meditation tasks and provided pre- and post-K10 data. Analysis showed that the mean pre-program K10 score was 17.2 (SD: 5.67), and the post-program score 14.7 (SD: 3.92). Using the Australian Bureau of Statistics risk categories, 46.3% of this sample was in the low risk category at the beginning of the skilling program. At the end of the 2 week home based program, 71.4% of the sample was in the low risk category, meaning that one-quarter (25.1%) of the at risk participants had improved sufficiently to shift into the low risk category. This difference was significant using McNemar’s test (p<0.001). The mean improvement of the at risk group’s K10 score was 20%.

Personal experience ratings

At the end of the seminar, 293 of the total 299 GP participants (98%) provided VASs that were suitable for inclusion in analysis. The results are summarised in Table 2.

Diary cards

Participants returned 163 diary cards, which showed day 1 compliance was 84.4% and day 14 compliance 77.4% (mean 79.5%). The mean mental silence rating on day 1 was 4.5 (SD: 2.3); on day 14 it was 6.3 (SD: 2.3), an improvement of 40%. A paired t-test indicated that this was significant (t=12.9, df=160, p<.001).

learning objectives survey

Feedback was very positive, with 98.8% of the 151 respondents indicating that their learning needs had been fully (54%) or partially (45%) met, and 97.5% indicating that the event was fully (56.0%) or partially (41.5%) relevant to their medical practice.

Relationship between mental silence experience and workshop outcomes

The relationship between participants’ self reported experience of ‘mental activity/silence’ in the VAS and their self reported experience of ‘calm/peaceful’ and ‘tension/anxiety/stress’ VASs was strong and highly significant, such that the more that participants’ mental activity moved toward the silent state, the more calm/peaceful (Spearman’s rank correlation test r=0.78, p<0.001) and the less tense/anxious/stressed they felt (r=0.70, p<0.001). In the diary card data, a significant relationship between self rated mental silence and K10 score at day 1, the day of the seminar (Spearman’s r=–0.36, p<0.001) and at day 14 (Spearman’s r=–0.25, p<0.01) was evident, such that a higher level (a higher self rated score) of mental silence was associated with a lower level of psychological distress (a lower K10 score). Among those GPs who rated the event highly there was a significant positive relationship between the change in mental silence rating and change in K10 score (r=0.26, p<0.05).

DiscussionKessler 10 scores indicate that the GPs who attended the event were experiencing high levels of psychological distress and that

Table 2. Change in qualitative experience as measured by visual analogue scores

Experiential factor

Any improvement

more than 50% improvement

more than 75% improvement

Mental silence 93% 40% 12%

Calm and peacefulness

96% 53% 23%

Stress, tension, anxiety

93% 46% 22%

Table 1. Participation and response rates

Category of participants Response rates (n)

Total medical practitioners participating (GPs, specialists, junior medical officers)

318

GPs 299

GPs who provided VAS data at the beginning of the workshop 293

GPs who completed baseline K10 questionnaire at the beginning of the workshop

283

GPs who completed both ‘before’ and ‘after’ K10 questionnaires 111

GPs who claimed CPD points 214

GPs who did the take home tasks (ALM) and earned Category 1 CPD points

163


Using meditation for less stress and better wellbeing – a seminar for GPsRESEARCH

458 AUStRAliAn FAmily PHySiCiAn Vol. 38, No. 6, June 2009

Volunteer meditation instructors: Dr Greg Turek, Robert Hutcheon, Paul and Colleen Keatley, and Robert Henshaw from Sahaja Yoga Australia. Sponsors: Jim Shelton, Ampco; Suzanne Coutinho, Australian Doctor; Displaycom; Healthed; Amit Vohra, GPRA.

References1. Holt J, Mar CD. Psychological distress among GPs. Aust Fam Physician 2005;34:599–602.2. Schattner P, Coman G. The stress of metropolitan general practice. Med J Aust

1998;169:133–7.3. Riley G. Understanding the stresses and strains of being a doctor. Med J Aust

2004;181:350.4. Cryer B, McCraty R, Childre D. Pull the plug on stress. Harvard Business Review

2003;81:118.5. Smith J. Relaxation, meditation, and mindfulness: A mental health practitioner’s guide

to new and traditional approaches. New York: Springer, 2005.6. Kaldor P, Francis L, Fisher J. Personality and spirituality: Christian prayer and Eastern

meditation are not the same. Pastoral Psychol 2002;50:165–72.7. Bellamy J, Castle K. 2001 Church attendance estimates. NCLS occasional papers.

Sydney: National Church Life Survey, 2004.8. Kaldor P, Bellamy J, Powell R. 1998 Australian community survey. Build my church:

Trends and possibilities for Australian churches. Adelaide: Openbook, 1999.9. Benson H. The relaxation response: its subjective and objective historical precedents

and physiology. Trends Neurosci 1983;6:281–4.10. Pirotta M, Cohen M, Kotsirilos V, Farish S. Complementary therapies: Have they

become accepted in general practice? Med J Aust 2000;172:105–9.11. Cohen M, Penman S, Pirotta M, Costa CD. The integration of complementary therapies

in Australian general practice: Results of a national survey. J Altern Complement Med 2005;11:995–1004.

12. Manocha R. Why Meditation? Aust Fam Physician 2000;29:1135–8.13. Manocha R. A randomised controlled trial of mental silence meditation for work stress.

10th International Congress of Behavioural Medicine. Tokyo: International Society of Behavioural Medicine and Japanese Society of Behavioural Medicine, 2008.

14. Morgan D. Sahaja yoga: An ancient path to modern mental health? Transpersonal Psychology Review 2000;4:41–9.

15. Manocha R, Marks G, Kenchington P, Peters D, Salome C. Sahaja yoga in the management of moderate to severe asthma: a randomised controlled trial. Thorax 2002;57:110–5.

16. Panjwani U, Gupta H, Singh S, Selvamurthy W, Rai U. Effect of Sahaja yoga practice on stress management in patients of epilepsy. Indian J Physiol Pharmacol 1995;39:111–6.

17. Panjwani U, Selvanurthy W, Singh S, Gupta H, Thakur L, Rai U. Effect of Sahaja yoga practice on seizure control and EEG changes in patients of epilepsy. Indian J Med Res 1996;103:165–72.

18. Grande ED, Taylor A, Wilson D et al. Mental health status of the South Australian population. Aust N Z J Public Health 2000;24:29–34.

19. Andrews G, Slade T. Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health 2001;25:494–7.

20. Australian Bureau of Statistics: Mental health and wellbeing: Profile of adults, Australia 1997, cat no. 4326.0. Canberra: ABS, 1998.

21. Marks J, Goldberg D, Hillier V. Determinants of the ability of general practitioners to detect psychiatric illness. Psychol Med 1979;9:337–53.

22. Boardman A. The general health questionnaire and the detection of emotional disorder by GPs: A replicated study. Br J Psychiatry 1987;151:373–87.

23. Howe A. Detecting psychological distress: Can general practitioners improve their own performance. Br J Gen Pract 1996;46:407–10.

24. Manuso. Testimony to the president’s commission on mental health. Washington: US Government Printing Office, 1978.

25. Corney R. A survey of professional help sought by patients for psychosocial problems. Br J Gen Pract 1990;40:365–8.

26. Bindman A, Forrest C, Britt H, Crampton P, Majeed A. Diagnostic scope of and expo-sure to primary care physicians in Australia, New Zealand and the United States: cross sectional analysis of results from three national surveys. BMJ 2007;334:1261.

27. Britt H, Miller G, Henderson J, Bayram C. Patient-based substudies from BEACH: Abstracts and research tools 1999–2006. Canberra: Australian Institute of Health and Welfare, 2007.

28. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385–96.

GPs suggested this course of action in their practice at least once per week, with 56% suggesting it at least once per month. Given this evidence, publicly accessible workshops, based on the model evaluated above, are a potentially useful referral pathway for primary health professionals.

implications for general practice•A low cost, nonprofit meditation workshop for GP wellbeing is

practically feasible and appealing to GPs. •AmeditationworkshopforGPshaspotentialasaneffectivemental

health promotion and prevention strategy. •Given the increasing attention on the issue of GP stress and

wellbeing, meditation represents an important addition to GPs’ self care resources.

Conflict of interest: Dr Raymond Seidler was paid an honorarium for the lecture.

AcknowledgmentsAssociate Professor Narelle Shadbolt, Doctors’ Health Advisory Service. Volunteer admin and support staff: Kellie Conroy, Samantha Elliot-Halls.

CORRESPONDENCE [email protected]

THE CHINESE UNIVERSITY OF HONG KONG

Applications are invited for:-

School of Public Health andDepartment of Community and Family Medicine

Assistant Professor (Clinical)(Ref. 0809/303(125)/2)

The School of Public Health and the Department of Community and Family Medicine arecommitted to assisting in the development of health systems, education and research in theregion. In view of the increasingly important discussion of reforms to the interface betweencommunity based care and public health within the healthcare system, the School and theDepartment are now jointly looking for professionals to fill the post of Assistant Professor(Clinical). Further information about the School and the Department is available athttp://www.sph.cuhk.edu.hk/cms and http://www.cuhk.edu.hk/med/cmd/index.html respectively.

Applicants should have (i) a medical qualification (approved for registration with TheMedical Council of Hong Kong); (ii) a professional qualification in family medicine (e.g.FRACGP, FHKCFP, MRCGP or equivalent); (iii) experience in public health or communityservices; and preferably (iv) good leadership and teaching skills. Main duties include (a)developing and participating in independent and/or collaborative research projects; (b)undertaking teaching and clinical duties; (c) supervising and coordinating coursedevelopment for undergraduate/postgraduate programmes. The appointee will be appointedjointly in the School of Public Health and the Department of Community and FamilyMedicine. Appointment will normally be made on contract basis for up to two years initiallycommencing as soon as possible, leading to longer-term appointment or substantiationlater subject to mutual agreement. Applications will be accepted until the post is filled.

Salary and Fringe BenefitsSalary will be highly competitive, commensurate with qualifications and experience. TheUniversity offers a comprehensive fringe benefit package including medical care, plus acontract-end gratuity for an appointment of two years, and a monthly fixed-sum cashallowance and a housing subsidy for eligible appointees.

Further information about the University and the general terms of service for appointmentsis available at http://www.cuhk.edu.hk/personnel. The terms mentioned herein are forreference only and are subject to revision by the University.

Application ProcedurePlease send full resume, copies of academic credentials, a publication list and/or abstractsof selected published papers together with names, addresses and fax numbers/e-mailaddresses of three referees to whom the applicants’ consent has been given for theirproviding references (unless otherwise specified), to the Personnel Office, The ChineseUniversity of Hong Kong, Shatin, N.T., Hong Kong (Fax: (852) 2603 6852). The PersonalInformation Collection Statement will be provided upon request. Please quote the referencenumber and mark ‘Application - Confidential’ on cover.

[Note: The University reserves the right not to fill the post or to fill the post by invitation.]


Australian Family Physician Vol. 29, No. 12, December 2000 • 1135

Why meditation?

Ramesh Manocha

Ramesh Manocha,

MBBS, BSc, is Barry

Wren Fellow, Royal

Hospital for Women,

New South Wales.

Meditation is seen by a number ofresearchers as potentially one of themost effective forms of stress reduction.1

While stress reduction techniques have been culti-vated and studied in the West for approximately70 years, the data indicates that they are not con-sistently effective.2

Meditation however, has been developed inEastern cultures and has a documented history ofmore than several thousand years. Eastern medita-tive techniques have been developed, trialed andrefined over hundreds of generations with the spe-cific intention of developing a method by whichthe layperson can regularly attain a state of mentalpeace and tranquillity, ie. relief from stress. It is astrategy that can easily be adapted to the needs ofclinicians and their patients in the West.

A US study for example, showed that a shortcourse of behaviour modification strategies thatincluded meditation led to significantly fewer visitsto physicians during the six months that followed.The savings were estimated at over $200 perp a t i e n t .3 A study of insurance statistics showedthat the use of medical care was significantly lessfor meditators compared to nonmeditators.4

The growing emphasis on:• quality of life outcomes• concepts such as psychoneuroimmunology or

mind–body medicine,5 and• reducing healthcare costssuggest that stress reduction and improving mentalhealth are becoming increasingly relevant tohealthcare.

The need for an evidenced basedapproachA recent survey of Australian general practition-ers showed that while GPs perceived meditation asan acceptable, even mainstream, health care strat-egy, it is paradoxically a poorly understooddiscipline. In view of this, the authors concludedthat well designed trials and education areurgently needed to inform GPs’ decision making.6

Meditation vs relaxation

Implicit in the fact that the term ‘meditation’ existsseparately from that of ‘relaxation’ suggests thatthere should be clear differences between the twophenomena. However, there is as yet insufficientevidence to draw a clear distinction. Moreover,researchers have yet to systematically compare dif-ferent techniques of meditation to determinewhether or not these techniques use different orsimilar mechanisms or have differing effect profiles.

Lack of quality research

Despite the breadth of information available on med-itation, a report of the US National Research Council(NRC) on meditation raised concerns about weakmethodology and poor definition of the process.7

Examining the literature using evidence basedcriteria reveals that while meditation does appearto have therapeutic potential, there is a greatneed for further research before definitive con-clusions can be made. The body of knowledgecurrently suggests that not all meditation tech-niques are the same; most techniques are

B A C K G R O U N D While many general practitioners perceive meditation as an acceptable, evenmainstream, health care strategy, it is paradoxically a poorly understood discipline.O B J E C T I V E To define meditation, outline the broad types of meditation and give an overview of theextent and validity of available evidence for its efficacy.D I S C U S S I O N The basic question of what constitutes meditation and what separates it from relaxationtherapy has been an impediment to formulating quality studies in order to research meditationtechniques. Examining the literature using evidence based criteria reveals that, while meditation doesappear to have therapeutic potential, there is a great need for further research before definitiveconclusions can be made. Researchers have yet to systematically compare different techniques ofmeditation to compare their profiles.

probably elaborate relaxation methods whilethere are others that may well involve physiologi-cal processes unique to meditation.

The Meditation Research Program (MRP) isone of the ongoing activit ies of the NaturalTherapies Unit at the Royal Hospital for Womenin Sydney. The MRP is committed to thorough sci-entific evaluation of meditation, its physiologicaleffects and its potential for healthcare.

What is meditation?

There are many forms of meditation, ranging incomplexity from strict, regulated practices to generalrecommendations. If practised regularly, meditationis thought to help develop habitual, unconsciousmicrobehaviours that can potentially produce wide-spread positive effects on physical and psychologicalfunctioning. Meditation even for 15 minutes twice aday has been shown to bring beneficial results.3

How does meditation work?

Parasympathetic response

Most theories are based on the assumption thatmeditation is a sophisticated form of relaxationinvolving a concept called the parasympatheticresponse. Psychological stress is associated withactivation of the sympathetic component of theautonomic nervous system which, in its extreme,causes the ‘fight or flight response’. Meditation andany form of rest or relaxation acts to reduce sym-pathetic activation by reducing the release ofcatecholamines and other stress hormones such ascortisol, and promoting increased parasympatheticactivity which in turn slows the heart rate andimproves the flow of blood to the viscera and awayfrom the periphery.

Other neurophysiological effects

Other proponents claim that meditation involvesunique neurophysiological effects; however, thisremains to be proven. Research at the MRP sug-gests the limbic system may be involved in Sahajayoga meditation (SYM) since significant effectsinvolving mood state have been consistentlyobserved.

Defining what we mean by meditation

The most important issue that must be addressed inthis field of research is to clearly define meditationand then subject that definition to scientific testing.

Meditation is popularly perceived to be anyactivity in which the individual’s attention is pri-marily focused on a repetitious cognitive activity.This very broad definition is, in the opinion of theMRP, the main cause for much of the inconsistentoutcomes seen in meditation research.

‘Thoughtless awareness’

If one closely examines the authentic tradition ofmeditation it is apparent that meditation is a discreteand well defined experience of a state called ‘thought-less awareness’. This is a state in which the excessiveand stress producing activity of the mind is neutralisedwithout reducing alertness and effectiveness.

Authentic meditation enables one to focus onthe ‘present moment’ rather than dwell on theunchangeable past or undetermined future. It isthis state of equipoise that is said to be therapeuticboth psychologically and physically and which fun-damentally distinguishes meditation from simplerelaxation, physical rest or sleep.

Reducing ‘background mental noise’

According to this perspective, stress is theinevitable byproduct of an overactive mind. Theunsilenced mind is responsible for almost continu-ous ‘background mental noise’ the content ofwhich is mostly unnecessary and unproductive. Yetit is this ‘mental noise’ that impinges on our other-wise natural tendency toward psychological,mental and spiritual health.

Quasi-meditation

Most commercialised meditation techniques do notreliably give the key experience of mental silenceor ‘thoughtless awareness’ hence they can moreprecisely be described as ‘quasi-meditative’. Theseinclude methods that use constant repetition ofsyllables (such as mantras), visualisations or otherthought forms.

This does not mean they may not be useful asthey do encourage relaxation by reducing or simplify-ing mental activity or focusing attention. However,well designed physiological and clinical trials have, onthe whole, shown little difference between these tech-niques and physical rest or relaxation.8

Types of meditation

There are many meditation techniques available toconsumers. Three notable examples include trans-cendental meditation, mindfulness and Sahaja yoga.

■ Why meditation?

1136 • Australian Family Physician Vol. 29, No. 12, December 2000

Transcendental meditation Transcendental meditation (TM) is the commonestform of mantra meditation. It aims to prevent dis-tracting thoughts by use of a mantra. Students areinstructed to be passive and, if thoughts other thanthe mantra come to mind, to notice them andreturn to the mantra. A TM student is asked topractise for 20 minutes in the morning and again inthe evening.

Transcendental meditation is said to be associ-ated with clinical outcomes such as blood pressurer e d u c t i o n9 and physiological changes such aslowered blood cortisol levels.10

Adverse effects

There are however, a number of case reports in themainstream medical literature describing occasionaladverse psychological1 1 , 1 2 and physical effects1 3 t h a tappear to be causally related to the technique.These adverse events range from mild to severe andwarrant further systematic investigation.1 4

Cost issues

The technique is taught using a commercial systemin which one begins by purchasing a mantra.Further instruction entails an escalating system offees that can be cost prohibitive. Moreover, the TMorganisation has on occasion been implicated inunethical and cultic practices.1 5 In light of this infor-mation, medical practitioners have no choice but torecommend caution with regard to this method.

Mindfulness and Vipassana meditation

Mindfulness is a general method that serves as abasis for techniques such as Vipassana meditation.It aims to use focused attention (often by using aphysical sensation such as the breath) to cultivatemental calmness. Regular practice enables one toobjectively observe one’s thoughts and thereforeenhance one’s self understanding. Mindfulnessapproaches have been shown to be effective incertain clinical applications such as chronic pain.16

Vipassana is both a general term referring to aspecialised form of mindfulness meditation andalso a specific brand name. The following informa-tion refers to the latter. Vipassana is taught inAustralia via a number of Vipassana retreats andcentres. The retreats involve up to 10 days of inten-sive meditation, several hours per day, and otherstrict observances such not talking and encourage-ment to maintain strict postures for long periods of

time. There is no fee for these retreats but ‘recom-mended donations’ are described. These retreatsare unsuitable for the average person, particularlythose unfamiliar with meditation, due to theextreme physical and psychological demands.Adverse events associated with Vipassana havebeen described although it is unclear as to whichform these reports refer.17

Sahaja yoga meditation

Sahaja yoga meditation (SYM) is the technique ofchoice in the MRP. Sahaja yoga meditation aims topromote the experience of ‘thoughtless awareness’based on the original meditative tradition.Meditators in the MRP consistently describe theability to achieve this experience. They are encour-aged to practise twice daily for approximately 15minutes. Sahaja yoga meditation is well suited forthe general population and for research, because itis easy to learn and is taught free of charge. Sahajayoga meditation is currently used in three Sydneyhospitals for patients, staff and public. Feedbackfrom management teams and anecdotal reportsfrom patients and carers are favourable. As yet noadverse effects have been reported in the MRP’strials, clinics or in the literature.

The MRP has conducted a number of small andlarge trials on SYM which have generated promis-ing results in Australian conditions. A randomisedcontrolled trial of meditation for moderate tosevere asthma compared SYM to a relaxationcontrol. SYM was more effective in a number ofobjective and subjective endpoints.

A number of locally conducted pilot studiesexamining the effect of SYM suggest that it mayhave a beneficial role in menopausal hot flushes,severe migraine and psychological stress.Randomised controlled trials are underway in orderto obtain definitive data. Studies in India suggestthat SYM is more beneficial than mimicking exer-cises in the treatment of epilepsy and hypertension.1 8

Recommending meditationtechniques to patients

General practitioners must exercise commonsenseand discrimination when recommending medita-tion to their patients as they have a duty of care toensure the safety of their patients’ health andfinances. Meditation is contraindicated in thosesuffering from psychosis and should only beapplied with great caution in those with severe psy-

Why meditation? ■

Australian Family Physician Vol. 29, No. 12, December 2000 • 1137

chological problems. The medicolegal implicationsof recommending a technique that leads to anadverse event have not been explored.

A simple and effective rule of thumb whenchoosing or recommending a meditation technique isto assume that ‘the best things in life are free’.Organisations involved in the commercialisation andmarketing of often costly ‘meditation’ techniques,courses and ‘master classes’ are least likely to beselling an authentic method. Unfortunately in thesesituations the welfare of the individual and the com-munity usually become secondary to profit or fame.

References1 . Hassed C. Meditation in general practice. Aust Fam

Physician 1996; 25(8):1257–1260.

2 . West M (ed). The psychology of meditation. Oxford:

Clarendon Press, 1987.

3 . Achterberg J. Mind body interventions, meditation. In:

Berman B. Alternative medicine, expanding medical

horizons. Washington DC: Office of Alternative

Medicine, National Institute of Health, 1992.

4 . McSherry. Medical economics. In: Wedding D, ed.

Medicine and behaviour. St Louis: Mosby and Co,

1 9 9 0 : 4 6 3 – 4 8 4 .

5 . Sommer S. Mind body medicine and holistic

approaches: The scientific evidence. Aust Fam

Physician 1996; 25(8)1233–1242.

6 . Pirotta M V, Cohen M M, Kotsirilos V, Farish S J.

Complementary therapies: Have they become accepted

in general practice? Med J Aust 2000; 172:105–109.

7 . Druckman D, Bjork R A, eds. In the mind’s eye:

enhancing human performance. Washington DC:

National Academy Press, 1991.

8 . Fenwick P B, Donaldson S, Gillis L, et al. Metabolic

and EEG changes during transcendental meditation: an

explanation. Biol Psychol 1977; 5(2):101–118.

9 . Schenider. In search of an optimal behavioural treat-

ment for hypertension: a review and focus on

transcendental meditation. In: Johnson E H, ed.

Personality, elevated blood pressure and essential

hypertension. Washington DC: Hemisphere.

1 0 . Maclean C, Walton K. Effects of the Transcendental

Meditation Program on adaptive mechanisms: Changes in

hormone levels and responses to stress after four months of

practice. Psychoneuroendocrinology. 1997; 22(4):

277–295.

1 1 . Heide F J, Borkovec T D. Relaxation induced anxiety:

Mechanism and theoretical implications. Behav Res

Ther 1984; 22:1–12.

1 2 . The various implications arising from the practice of

transcendental meditation: an empirical analysis of

pathogenic structures as an aid in counselling.

Bensheim, Germany: (Insti tut fur Jugend und

Gesellschaft, Ernst-Ludwig-Strasse 45, 6140); The

Institute for Youth and Society, 1980.

1 3 . Persinger M A. Transcendental meditation and general

meditation are associated with enhanced complex

partial epileptic-like signs: evidence for cognitive kin-

dling? Percept Mot Skills 1993; 76:80–82.

1 4 . Otis L S. Adverse effects of transcendental meditation.

In: Shapiro D, Walsh R, eds. Meditation: classic and

contemporary perspectives. New York: Alden, 1984.

1 5 . Skolnick A. Maharishi Ayur-Veda: Guru’s marketing

scheme promises the world eternal perfect health!

JAMA 1991; 266(10):1741–1750.

1 6 . Kabat-Zinn J, Lipworth L, Burney R, et al. The clinical

use of mindfulness meditation for the self regulation of

chronic pain. J Behav Med 1998; 8(163):190.

1 7 . Shapiro D, Deane H. Adverse effects of meditation: A

preliminary investigation of long term meditators. Int J

Psychosom 1992; 39:1–4; SI:62–67.

1 8 . Panjwani U, Selvamurthy W, Singh S H, Gupta H L,

Thakur L, Rai U C. Effect of Sahaja yoga practice on

seizure control & EEG changes in patients of epilepsy.

Ind J Med Res 1996; 103(3):165–72.

■ Why meditation?

1138 • Australian Family Physician Vol. 29, No. 12, December 2000

R E P R I N T R E Q U E S T S

Dr Ramesh Manocha

Natural Therapies Unit

Royal Hospital for Women

Locked Bag 2000

Randwick, NSW 2031

Email: [email protected]

• Meditation can be an effective form ofstress reduction and has the potential toimprove quality of life and decreasehealthcare costs.

• Although meditation differs from relaxationtechniques, the components whichconstitute this difference have not yet beenclearly defined.

• Meditation involves achieving a state of‘thoughtless awareness’ in which theexcessive stress producing activity of themind is neutralised without reducingalertness and effectiveness.

• Authentic meditation enables one to focus onthe present moment rather than dwell on theunchangeable past or undetermined future.

• There is little quality evidence comparingone meditation technique with another ormeditation with relaxation techniques.

• The theoretical explanation for the effects ofmeditation and relaxation techniques is thatthe release of catecholamines and otherstress hormones are reduced andparasympathetic activity is increased.

• Whether meditation involves other uniqueneurophysiological effects remains to be proven.

S U M M A R Y O F I M P O R T A N T P O I N T S

40 MEDICAL OBSERVER 13 AUGUST 2004

MO clinicalreview

herbs in focus alternative viewcoordinated by Associate Professor John Eden

MEDITATION is becoming increasinglypopular with Western consumers. Arecent survey of Australian GPs foundthat almost 80% had recommendedmeditation at least once,1 and a survey ofAustralian consumers found that about10% of the population had tried or werecurrently practising it.2

Within scientific literature, meditationis a poorly defined and heterogenous col-lection of methods aimed at achievingstates of relaxation and better well-beingby using structured exercises to focusattention and modify thinking activity.

Consumers perceive meditation to beuniquely effective, and researchers haveinvestigated meditation to determinewhether these specific effects exist.

MEDITATION RESEARCHThe Natural Therapies Research Unit(NTU) at the Royal Hospital for Womenin Sydney recently completed a systematicreview of the scientific evidence for med-itation. Of more than 3200 articles onmeditation in peer-reviewed literature,less than 100 (about 3%) were ran-domised controlled trials (RCTs).

While the majority of these RCTsreported positive effects of meditation,more than two-thirds failed to properlyaddress the placebo effect – the mostimportant confounder in medical research.

People are understood to respond sim-ilarly to almost any behaviour therapy,even sham therapies, simply because thetherapies involve non-specific effectssuch as regular contact with a therapist,the simple effects of rest and relaxation,and the natural tendency to get better,not to mention pressure from researchersto report improvements. All of these fac-tors contribute to the placebo effect.

MEDITATION EFFECTIVENESSA statistically significant pattern emergedwhen the RCTs were rated according tothe credibility of control method. Whilealmost all trials using inactive and non-credible controls reported positiveeffects, those using more credible andactive controls reported considerably less

favourable outcomes. In fact, most trialsthat compared genuine meditation tech-niques with elaborately designed andexecuted sham procedures did not reportany significant differences. However,some trials have shown exceptions.

SAHAJA YOGASahaja yoga is noted as a promising tech-nique, with positive results demonstratedin pilot studies in India.

Recently, the NTU conducted an RCTthat compared sahaja yoga with a credi-ble stress management program for peo-ple with moderate to severe asthma onprestabilised treatment, but who remainedsymptomatic. Both groups experiencedsimilar improvements in a number ofoutcome measures, but the yoga groupdemonstrated significantly greaterimprovements in key measures of emo-tional health and quality of life. Mostimportantly, the meditation approachgenerated significant changes in airwayhyper-responsiveness, suggesting thatthis technique may actually impact onpathophysiological processes.4

Further, the NTU has just concluded alarge, independently funded RCT inwhich sahaja yoga was compared with ageneric form of meditation for stress andanxiety. Sahaja yoga was found to be significantly more effective than thegeneric approach in reducing stress, anx-iety and depressive symptoms. The criti-cal difference between the approaches isthought to be the ability of the sahajatechnique to elicit a specific state of‘mental silence’ in which the meditator isfully alert and aware but does not expe-rience unnecessary mental activity.

Brain imaging studies have shown thatthis approach to meditation is associatedwith reproducible patterns of brainactivity that correlate with subjectiveexperience of mental silence.5,6

INDICATIONSMeditation is indicated in any scenariowhen stress and anxiety may be con-tributing factors. It is ideally suited toconditions that cause subobtimal qualityof life and well-being, such as workstress, primary insomnia and mild anxi-ety. Also, it is useful as an adjunct in themanagement of severe, chronic or termi-nal illness.

CONTRAINDICATIONS AND SIDE-EFFECTSMeditation is contraindicated in patientswith severe mental illness, particular ifthere is a risk of psychosis, and should besupervised closely if used by anyone withmild to moderate mental illness. There isevidence of adverse effect, mostly associ-ated with commercialised methods.7

CONCLUSIONIf faced with a choice between user-paysmeditation lessons and regular time outto sit quietly in a comfortable chair or toenjoy a pastime, scientific evidence sug-gests the latter is equally efficacious,cheaper and more accessible. However, if

a patient is keen to try meditation, recommend a technique that has genuineevidence of efficacy, and is learned easily,such as sahaja yoga. MO

Dr Ramesh Manocha is a Barry Wren Fellow atthe Natural Therapies Unit, Royal Hospital forWomen, Sydney.Associate Professor John Eden, MBBS, MD,MRCOG, FRANZCOG, MRACOG, CREI, isdirector of the Sydney Menopause Centre andNatural Therapies Unit, Royal Hospital forWomen, Sydney.

References available fromwww.medicalobserver.com.au

Making sense of meditationDr Ramesh Manochaconsiders the effectiveness of meditation as a treatment.

clinicaltrials

QUEENSLAND researchers are looking for patients with osteoarthritis to participate in a study looking at the effectiveness of ahomeopathic treatment for the condition.

The trial, conducted by the Southern Cross University with the University ofQueensland, aims to establish whetherhomeopathy can provide safe and

effective relief of symptoms in patients witharthritis.

“Sufferers of osteoarthritis are desperatelylooking for effective treatments to reduce theirpain and other symptoms,” PhD student andresearch coordinator Don Baker said.

More than 60% of Australians used someform of alternative therapy, Mr Baker said.

And a feature of the homeopathic treatmentwas that it did not appear to have the negativeside-effects sometimes associated with moreconventional treatments.

The researchers are looking for peoplediagnosed with osteoarthritis of the hip or knee, aged between 18 and 85 years, who areotherwise healthy and who are willing to ceaseall other arthritis treatment for eight weeks.

The study will involve an initial four-week

period without treatment, followed by fourweeks of treatment, involving a one-off dose of homeopathic pills, followed by an oral spraythree times a day for a month.

Volunteers are expected to attend a clinic at the Southern Cross University’s Lismore orGold Coast campus on three occasions.

For further details, contact Mr Baker in theSouthern Cross University School of Natural andComplementary Medicine on 1300 78 55 89.

Osteoarthritis and homeopathy study

Meditation is held to be uniquely effective, and researchers have investigated whether specific effects exist.

ORIGINAL ARTICLE

Sahaja yoga in the management of moderate to severeasthma: a randomised controlled trialR Manocha, G B Marks, P Kenchington, D Peters, C M Salome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Thorax 2002;57:110–115

Background: Sahaja Yoga is a traditional system of meditation based on yogic principles which maybe used for therapeutic purposes. A study was undertaken to assess the effectiveness of this therapy asan adjunctive tool in the management of asthma in adult patients who remained symptomatic on mod-erate to high doses of inhaled steroids.Methods: A parallel group, double blind, randomised controlled trial was conducted. Subjects wererandomly allocated to Sahaja yoga and control intervention groups. Both the yoga and the controlinterventions required the subjects to attend a 2 hour session once a week for 4 months. Asthma relatedquality of life (AQLQ, range 0–4), Profile of Mood States (POMS), level of airway hyperresponsivenessto methacholine (AHR), and a diary card based combined asthma score (CAS, range 0–12) reflectingsymptoms, bronchodilator usage, and peak expiratory flow rates were measured at the end of thetreatment period and again 2 months later.Results: Twenty one of 30 subjects randomised to the yoga intervention and 26 of 29 subjectsrandomised to the control group were available for assessment at the end of treatment. The improve-ment in AHR at the end of treatment was 1.5 doubling doses (95% confidence interval (CI) 0.0 to 2.9,p=0.047) greater in the yoga intervention group than in the control group. Differences in AQLQ score(0.41, 95% CI –0.04 to 0.86) and CAS (0.9, 95% CI –0.9 to 2.7) were not significant (p>0.05). TheAQLQ mood subscale did improve more in the yoga group than in the control group (difference 0.63,95% CI 0.06 to 1.20), as did the summary POMS score (difference 18.4, 95% CI 0.2 to 36.5,p=0.05). There were no significant differences between the two groups at the 2 month follow upassessment.Conclusions: This randomised controlled trial has shown that the practice of Sahaja yoga does havelimited beneficial effects on some objective and subjective measures of the impact of asthma. Furtherwork is required to understand the mechanism underlying the observed effects and to establish whetherelements of this intervention may be clinically valuable in patients with severe asthma.

There is a long history of psychosomatic theories for theaetiology of asthma1 and of investigations into the role ofanxiety and emotional states in outcomes of the disease.2

Various psychological interventions have been implementedin patients with asthma. At least one trial of hypnosis hasyielded a positive result,3 but relaxation alone was not effectivein a recent trial.4 Buteyko breathing, a method of controlledbreathing, has recently attracted attention in Australia andsome preliminary evidence suggests that it may havebeneficial effects.5 Singh et al6 have shown that regular use of adevice which slows breathing and changes the ratio ofinspiratory to expiratory time, in a manner equivalent to pra-nayama yoga breathing methods, decreases airway hyperre-sponsiveness (AHR) in asthmatic subjects.

Sahaja yoga is an Indian system of meditation based on tra-ditional yogic principles which may be used for therapeuticpurposes. A small clinical trial of this therapy in patients withasthma found evidence of improvement in lung function andreduced frequency of “attacks”.7

The optimal management of patients with asthma whoremain symptomatic on moderate to high doses of inhaledsteroids remains undefined. Pharmacological alternativesinclude further increases in the dose of inhaled steroids, addi-tion of long acting β2 agonists,8 or introduction of leukotrienereceptor antagonists.9 The role of non-pharmacological thera-pies, including psychological and physical techniques, in thiscontext has not been well established to date.

We sought to assess the effectiveness of a non-pharmacological intervention, Sahaja yoga, as an adjunctivetool in the management of asthma in adult patients who

remained symptomatic on moderate to high doses of inhaled

steroids. In particular, we examined its effect on asthma

related quality of life, mood state, level of airway hyperrespon-

siveness, and a diary card based score reflecting symptoms,

bronchodilator usage, and peak expiratory flow (PEF) rates.

METHODSStudy designA parallel group, double blind, randomised controlled trial was

conducted. After a 2 week baseline assessment period,

subjects were randomly allocated to Sahaja yoga and control

intervention groups. Both the yoga and the control interven-

tions required the subjects to attend a 2 hour session once a

week for 4 months. Subjects were informed that the project

aimed to assess the relative effectiveness of two alternative

relaxation techniques for the management of asthma.

Outcome assessments were undertaken at the conclusion of

the 4 month intervention period and again 2 months later.

Allocation to groups was by randomised permuted blocks

with a block size of four. The allocation for each successive

subject was contained within a sealed envelope.

The study protocol was approved by the Institutional Ethics

Committees of the South Western Sydney Area Health Service

and the Central Sydney Area Health Service. Informed

consent was obtained from subjects prior to randomisation.

Subject selectionThe aim was to select adult patients with asthma who

remained poorly controlled on moderate to high doses of

See end of article forauthors’ affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Dr G B Marks, Institute ofRespiratory Medicine, P OBox M77, Camperdown,NSW 2050, Australia;[email protected]

Revised version received5 July 2001Accepted for publication15 August 2001. . . . . . . . . . . . . . . . . . . . . . .

110

www.thoraxjnl.com

inhaled steroids and who were amenable to the idea of a non-

pharmacological stress management intervention.

Subjects were recruited by newspaper advertisement

(n=850 responses), review of asthma clinic records (n=200

reviewed), and through local general practitioners (n=30

referrals). Subjects with asthma were eligible for inclusion in

the study if they were aged 16 or over and had a history of

asthma symptoms for a least 1 year. Other inclusion criteria

were: at least moderate to severe asthma as evidenced by a

combined asthma score of 7 or more out of 12 (see below)10;

airway hyperresponsiveness (PD20FEV1 <12.2 µmol metha-

choline) or >15% FEV1 bronchodilator response; daily inhaled

treatment with >1500 µg beclomethasone, 1200 µg budeso-

nide or 750 µg fluticasone for at least the preceding 6 weeks;

and stable asthma treatment for the preceding 6 weeks. Sub-

jects with a history of an exacerbation or respiratory tract

infections in the preceding 6 weeks, current smokers,

pregnant or lactating women, and those who could not com-

municate in English were excluded.

Sahaja yoga interventionThe key experience of Sahaja yoga meditation is a state called

“thoughtless awareness” or “mental silence” in which the

meditator is fully alert and aware but is free of any unneces-

sary mental activity. The Sahaja yoga session was conducted

by an experienced instructor who taught subjects how to

achieve this state by the use of silent psychological

affirmations. The weekly sessions involved meditation, in-

structional videos, personalised instruction, and discussion of

problems in relation to improving the experience of medita-

tion. Subjects were encouraged to achieve this state of mental

silence for a period of 10–20 minutes twice each day.

Control interventionThe control intervention included relaxation methods, group

discussion, and cognitive behaviour therapy-like exercises.

Relaxation methods involved positive affirmations such as “I

can breathe easily and without restriction”, progressive mus-

cle relaxation, and visualisation (focusing on seeing their

lungs breathing easily). Group discussion was semi-formal

and enabled participants to share experiences and develop a

sense of community. The cognitive behaviour therapy-like

exercises were designed to give the subject insight into the

way in which their thoughts, feelings, and reactions to stress

influenced the severity and perception of their illness. This

approach was based on a workbook on relaxation and stress

management techniques called Learning to Unwind.11 The

sessions were conducted by an experienced instructor.

Subjects were encouraged to practise the techniques at home

for 10–20 minutes twice daily.

Both the yoga and control techniques were practised with

the subject seated. Treatment with inhaled steroids, long act-

ing β2 agonists, and/or theophylline was continued unchanged

throughout the study period.

Outcome measurementsOutcome assessments at baseline, at the end of the interven-

tion, and 2 months after the end of the intervention were

undertaken by an investigator who was blind to the group

allocation of the subjects.Subjects kept written diary cards to record twice daily PEF

rates, symptoms, and bronchodilator use for 2 week periods ateach assessment. Each of these was scored as shown in table1. The combined asthma score,10 the sum of these three com-ponents, was then calculated for each subject for each assess-ment period. The possible range of scores was 0–12. Inaddition, mean morning peak flow (am PEF) and lowest peakflow as a percentage of the highest peak flow (low%high) werecalculated for each diary card.

At each assessment subjects completed a questionnaire toassess changes in medication compared with baseline. Adisease specific asthma quality of life questionnaire (AQLQ,University of Sydney)12 and a measure of mood states, theProfile of Mood States (POMS),13 were also administered. TotalAQLQ scores and subscale scores for breathlessness, mooddisturbance, social disruption, and concerns for health werecalculated on a scale of 0 (no impairment of quality of life) to4 (maximum impairment). POMS scores for tension, depres-sion, anger, vigour, fatigue, confusion, and a summary moodscore were calculated.

Spirometric function was measured at least 4 hours afterthe last dose of short acting bronchodilator and 12 hours afterthe last dose of long acting bronchodilator. A methacholinechallenge test was performed to assess airway responsivenessin subjects who did not have severe airflow obstruction (gen-erally, FEV1 >60% predicted14) at baseline. The challenge wasperformed by the rapid method using a hand held DeVilbissNo 45 nebuliser to administer cumulative doses of metha-choline in the doses of 0.1–12.2 µmol.15 The provoking doserequired to cause a 20% reduction in FEV1 from the post-salinevalue (PD20FEV1) was measured by linear interpolation on alog-dose response curve or by linear extrapolation to a maxi-mum of twice the final dose administered. All extrapolatedvalues greater than this were assigned a value of twice thefinal cumulative dose. Values of PD20FEV1 were log trans-formed for analysis. Change in PD20FEV1 was expressed inunits of doubling doses.

Data analysis and sample sizeAnalysis was by intention to treat. Primary outcome variables

were the combined asthma score, the AQLQ (Total) score, and

PD20FEV1. All other outcomes were secondary outcome

variables.All outcomes measured at the conclusion of the interven-

tion and 2 months later were expressed as changes from base-line. Between group differences in these changes werecalculated, together with 95% confidence intervals. Thechanges were compared by the unpaired (two sample) t test.For non-normally distributed data Wilcoxon’s non-parametrictest was used to check the results of the parametric analysis.

Table 1 Scoring key for diary card recordings of symptoms, bronchodilator usage, and peak expiratory flow (PEF)rates10

Score Symptoms Bronchodilator usageMin morning PEFas % of best*

0 Nil Nil >93%1 No night symptoms; daytime symptoms <2 times (in 2/52) Used on <2 days (in 2/52) >85 and <93%2 No night symptoms; daytime symptoms >2 times but <10 times

(in 2/52)Used on >2 days but <10 days (in 2/52) >78 and <85%

3 Night symptoms <2 times (in 2/52) OR daytime symptoms >10times (in 2/52)

Used on >10 days, average 1–2 times/day >70 and <78%

4 Daytime symptoms every day OR night symptoms >2 times(in 2/52)

Used on >10 days, average 3 times or more per day <70%

*“Best” includes clinic spirometric tests and all PEF records.

Sahaja yoga in the management of asthma 111

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Details of subjects’ record of attendance at the Sahaja yogaand control group sessions were quantified to assesscompliance.

We estimated that a sample size of 25 in each group wouldallow us to detect a difference between groups in PD20 of onedoubling dose with 80% power (α = 0.05). This sample sizewould also be sufficient to detect a clinically meaningfuldifference in AQLQ scores between the groups.16 To ensure 25subjects were available for evaluation we planned to ran-domise 30 subjects into each group.

RESULTSSubjectsOf 120 subjects who appeared suitable for the study on the

basis of initial telephone interview, 59 eligible subjects were

finally randomised: 30 to the Sahaja yoga intervention and 29

to the control arm. Nine subjects randomised to the yoga

intervention and three subjects randomised to the control

group withdrew before the end of treatment assessment. No

outcome data are available for these subjects. The reasons for

withdrawal are shown in table 2.Differences at baseline between the randomisation groups

and between those who did and did not complete the end oftreatment assessment are shown in table 3. Subjects in theyoga group had slightly higher (worse) scores on the moodsubscale of the AQLQ and higher PEF values (low%high) thanthose in the control group. Five subjects in each group wereusing long acting β2 agonists and one subject in each groupwas taking theophylline.

Of the 21 subjects in the yoga group who had the end oftreatment assessment, five did not have a methacholine chal-lenge at baseline (all because of a pre-test FEV1 of <60% pre-dicted), four did not have a challenge at the end of treatment

(two because of a pre-test FEV1 of <60% predicted), and six

did not have a challenge at end of the 2 month follow up

period (four because of a pre-test FEV1 of <60% predicted). Of

the 26 control group subjects who had the end of treatment

assessment, one was lost to follow up before the 2 month fol-

low up assessment and one did not complete the diary cards or

questionnaires at the end of the treatment period or the 2

month follow up period. In addition, seven did not have a

methacholine challenge test at baseline (six because of a pre-

test FEV1 of <60% predicted), eight did not have a challenge at

the end of the treatment period (seven because of a pre-test

FEV1 <60% predicted), and nine of the continuing partici-

pants did not have a challenge at the end of the 2 month fol-

low up period (eight because of a pre-test FEV1 of <60% pre-

dicted).

Adherence to the interventionTwenty of the 21 subjects in the yoga intervention group who

had the end of treatment assessment attended at least eight of

the 16 yoga sessions. Seventeen of these attended 12 or more

sessions and five attended all 16 sessions. In the control group

19 of the 26 who had the end of treatment assessment

attended at least eight sessions, 17 attended 12 or more

sessions, and 12 attended all 16 sessions.

Principal outcome measuresAt the end of the treatment period the level of AHR had

improved by 1.6 doubling doses (95% confidence interval (CI)

0.6 to 2.7) in the yoga intervention group and by 0.2 doubling

doses (95% CI−0.8 to 1.2) in the control group (p=0.047 for

between group difference). The difference between the groups

was no longer significant 2 months after the end of treatment

(fig 1, table 4).

The exclusion of data for occasions when methacholine

challenge tests could not be performed because of low lung

function potentially could have biased this analysis of change

in AHR. In a sensitivity analysis the change in PD20FEV1 was

re-calculated with PD20FEV1 assigned to a value of 0.1 µmol

(equivalent to severe AHR) for those occasions when a

challenge was not performed because the pre-test FEV1 was

<60% predicted. The findings of this sensitivity analysis were

similar to those of the primary analysis. This analysis showed

that, at the end of treatment, the improvement in AHR was 1.9

doubling doses greater in the yoga intervention group than in

Table 2 Reasons for withdrawal of subjects from thestudy

Sahaja yoga Control

Social/work changes 4 0Illness unrelated to intervention 2 1Disliked the intervention 1 0Changed management regimen 2 2

Table 3 Baseline demographic and clinical characteristics of study subjects

Yoga Control

Randomised Complete* Randomised Complete*

Number 30 21 29 26Mean age (years) 36 37 36 37Female (n) 14 11 17 15Ex-smokers (n) 10 7 11 10Duration of asthma (years) 25 25 22 22Mean inhaled steroid dose (µg)† 2458 2274 1927 1918Mean FEV1 (% predicted) 75% 76% 76% 73%Mean FEV1/FVC ratio 0.70 0.71 0.75 0.74Mean AQLQ Total score 1.7 1.5 1.5 1.5Mean AQLQ Breathlessness score 1.5 1.4 1.5 1.5Mean AQLQ Mood score 1.7 1.8 1.3 1.3Mean AQLQ Social score 1.4 1.2 1.4 1.5Mean AQLQ Concerns score 1.9 1.7 1.6 1.7Mean morning peak flow 369 372 365 363Peak flow (low % high) 76% 77% 72% 70%CAS‡ (max 12) 10 10 10 10PD20FEV1 (µmol) 1.20 (n = 22) 1.51 (n = 16) 1.21 (n = 22) 1.29 (n = 19)

FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; AQLQ = asthma related quality oflife questionnaire; CAS = combined asthma score; PD20FEV1 = dose of methacholine provoking a fall in FEV1

of 20% or more. *Subjects who had outcome assessments performed at the end of the treatment period.†Daily dose of inhaled steroids in beclomethasone µg equivalents. These were calculated on the assumptionthat beclomethasone 2000 µg = budesonide 1600 µg = fluticasone 1000 µg. ‡Median values.

112 Manocha, Marks, Kenchington, et al

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the control group (95% CI 0.7 to 3.4, p=0.004). At the end of

the 2 month follow up period the improvement in AHR, esti-

mated in this sensitivity analysis, was 1.2 doubling doses

greater in the yoga intervention group than in the control

group (95% CI –0.4 to 2.8, p=0.1).

The improvement in AQLQ score at the end of the treatment

period was 0.41 units greater in the yoga group than in the

control group. This difference just failed to reach statistical

significance (p=0.07). There was no between group difference

in the change in AQLQ scores 2 months after the intervention

was completed (table 4). There was no difference between the

two groups in the CAS either at the end of the treatment

period or at the 2 month follow up assessment.

Secondary outcome measuresExamination of the subscale scores from the AQLQ reveals

that the major impact of yoga was on the “mood” subscale (fig

2). At the end of treatment there was significantly greater

improvement in this subscale in the yoga group than in the

control group. A slightly lesser difference, which just failed to

reach statistical significance, was still evident 2 months after

the end of treatment. The “breathlessness” subscale tended to

reflect greater benefits from the yoga intervention than the

“social” or “concerns” subscales.

At the end of the intervention period the yoga group had

greater beneficial changes in POMS tension and fatigue scales

and in the summary mood measure than the control group

(fig 2). However, at the follow up examination, although there

were similar trends in these scales, the differences were no

longer significant.

Figure 1 Changes in airway responsiveness to methacholine.PD20FEV1 (µmol methacholine) at baseline, at the end of theintervention, and 2 months after the end of the intervention in theyoga group (triangles, solid line) and the control group (circles,broken line) are shown. The reference line indicates a value of12.2 µmol, the maximum dose of methacholine administered duringthe challenges. Values above this line were calculated byextrapolation.

Baseline End of intervention End of follow up

10

1

0.1

PD20FEV1

Figure 2 (A), (B) Changes in Asthma Quality of Life Questionnaire score (AQLQ) and (C), (D) Profile of Moods States (POMS) at the end ofthe intervention (A and C) and 2 months after the end of the intervention (B and D) in the yoga group (filled circles) and the control group (opencircles). The diamond indicates the mean difference between the two groups (change in yoga group – change in control group) and the errorbars represent the 95% confidence interval around the mean difference. A positive change in the AQLQ score indicates an improvement inquality of life. A positive change in the POMS component scores indicates a reduction in the attribute (that is, an improvement in all scalesexcept vigour). A positive change in the total POMS score indicates an improvement in mood.

_1 0

AQLQ score

1 2

Concerns

Social

Mood

Breathlessness

Total

End of interventionA

_1 0

AQLQ score

1 2

Concerns

Social

Mood

Breathlessness

Total

Two months after interventionB

_10

POMS score

Confusion/

bewilderment

Fatigue

Vigour

Anger-hostility

Depression-

dejection

Tension-

anxiety

Total

End of interventionC

0 10 20 30 40_10

POMS score

Confusion/

bewilderment

Fatigue

Vigour

Anger-hostility

Depression-

dejection

Tension-

anxiety

Total

Two months after interventionD

0 10 20 30 40


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There were no significant changes in lung function as

measured by spirometric tests during clinic visits or as

measured by peak flow at home (table 4).

DISCUSSIONSahaja yoga improved AHR and some aspects of impairment

of AQLQ and mood in patients with asthma who had

remained symptomatic despite treatment with moderate to

high dose inhaled steroids for at least 6 weeks. The benefits of

yoga on these outcomes were greater than the benefits of

relaxation alone. The magnitude of the beneficial change in

AHR due to the yoga intervention in this study was

approximately equivalent to that attributed to inhaled

corticosteroids in patients with asthma in previous studies.17

However, these improvements were not accompanied by

changes in lung function or symptoms recorded by diary card

and appeared to wane over a period of 2 months after the

intervention ceases.

The conclusions of this study are generalisable to subjects

with symptomatic asthma who express interest in the

non-pharmacological therapies but may not be applicable to

patients who are antipathetic to this form of treatment.

Although the use of complementary treatments for asthma is

not frequently reported to treating doctors, their use was

common among members of the UK’s National Asthma

Campaign18 in which 30% of respondents reported that they

had used breathing techniques to relieve symptoms.19

It is important to note that the role of yoga was assessed as

an adjunctive treatment. All subjects had been taking the

equivalent of beclomethasone 1500 µg /day for at least 6 weeks

before randomisation and they continued on this treatment

throughout the intervention and follow up period. Hence, the

benefits of yoga are additional to the benefits of inhaled ster-

oids. We have not tested the role of yoga as a replacement for

inhaled steroids and cannot deduce whether the beneficial

effects of yoga require the simultaneous use of inhaled

steroids.

One of the strengths of this study is the use of a plausible

control intervention. The relatively good adherence to the

intervention by the control group participants is evidence of

our success in blinding participants to the active versus

control status of the alternative intervention groups. Unex-

pected substantial improvements in symptom scores and

quality of life in the control group, presumably due to

non-specific effects of both interventions and the trial itself,

may have limited our ability to detect further benefits which

were specific to the Sahaja yoga intervention.

There was a larger than expected loss to follow up in yoga

treatment group. The availability of outcome data on only 21

subjects in this group was less than the 25 estimated in the

sample size calculations. This left the study slightly under-

powered and, hence, the failure to detect a significant

treatment effect on AQLQ (Total) score may be a type II error.

The higher than expected dropout rate in the yoga

treatment group does introduce a potential problem with bias

due to selective withdrawal of subjects who were not benefit-

ing from the intervention. However, most of these withdraw-

als occurred soon after randomisation and are therefore

unlikely to be related to the effectiveness of the intervention.

Among those who did reach the end of treatment

assessment, compliance with the yoga and control treatments

was good. Most subjects attended most of the sessions. How-

ever, we do not have any quantitative data on adherence to

yoga practices between the actual sessions or during the post-

intervention follow up period. We have anecdotal evidence to

suggest that there was poor maintenance of meditation prac-

tices after the end of the intervention period. It is likely that

this explains the lack of efficacy at the follow up assessment.

The findings reported here lend some support to the

conclusions of a previous small randomised controlled trial of

Tab

le4

Cha

nge

from

base

line

inou

tcom

em

easu

res

End

ofin

terv

entio

nTw

om

onth

saf

ter

inte

rven

tion

nYo

gaC

ontr

olD

iffer

ence

*(9

5%

CI)

pva

lue

nYo

gaC

ontr

olD

iffer

ence

*(9

5%

CI)

pva

lue

Com

bine

dA

sthm

aSc

ore

(max

scor

e12

)46

2.9

2.0

0.9

(–0.

9to

2.7)

0.3

452.

02.

5–0

.5(–

2.2

to1.

2)0.

6A

QLQ

(Tot

al)(

max

scor

e4)

461.

050.

650.

41(–

0.04

to0.

86)

0.07

450.

880.

630.

25(–

0.21

to0.

72)

0.3

PD20

FEV 1

(dou

blin

gdo

ses)

32–1

.64

–0.1

8–1

.46

(–2.

89to

–0.0

2)0.

047

26–1

.57

–0.7

4–0

.84

(–2.

37to

0.70

)0.

3FE

V 1(%

pred

icte

d)47

–4.2

0.6

–4.8

(–13

.1to

3.5)

0.3

44–0

.9–1

.91.

0(–

8.1

to10

.1)

0.8

FEV 1

/FVC

ratio

47–0

.008

0.00

3–0

.011

(–0.

047

to0.

024)

0.5

44–0

.033

–0.0

02–0

.031

(–0.

085

to0.

023)

0.3

Mor

ning

PEF

(l/m

in)

461.

72.

4–0

.7(–

18.4

to17

.0)

0.9

461.

6–1

.43.

1(–

13.0

to19

.1)

0.7

PEF

(low

%hi

gh)

46–6

.7–6

.5–0

.1(–

6.1

to5.

8)0.

9745

–4.5

–8.5

4.0

(–3.

4to

11.4

)0.

3

AQ

LQ=

asth

ma

rela

ted

qual

ityof

life

ques

tionn

aire

;FEV

1=

forc

edex

pira

tory

volu

me

in1

seco

nd;F

VC=

forc

edvi

talc

apac

ity;P

D20

FEV 1

=do

seof

met

hach

olin

epr

ovok

ing

afa

llin

FEV 1

of20

%or

mor

e.*C

hang

ein

yoga

grou

p–

chan

gein

cont

rolg

roup

,diff

eren

ces

teste

dby

unpa

ired

(two

sam

ple)

ttes

t.

114 Manocha, Marks, Kenchington, et al

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the effectiveness of Sahaja yoga in the management of asthma

in adult women.7 In nine patients randomised to the

intervention group the FEV1/FVC ratio increased from 48% at

baseline to 66% at the conclusion of the 4 month intervention

period. Over the same period the spirometric ratio did not

change in nine control subjects (p<0.001). Subjects in the

intervention group had an average of 5.8 “acute attacks” dur-

ing the treatment period compared with 12.9 “acute attacks”

over the same period in the controls (p<0.001).

Meditation is designed to help the individual develop a state

of mind which is positive or benevolent towards oneself and

others. The ideal state of mind has been described as “Sahaja”,

meaning spontaneous or effortless. The experience of medita-

tion is essentially the Sahaja state. The yogic tradition encour-

ages aspirants to pursue the awakening of an energy,

traditionally known as “kundalini”, that facilitates the

achievement of the Sahaja state. The meditative experience is

characterised by a sensation of normal, or even heightened,

alertness in conjunction with a state of complete mental

silence. This is associated with a sense of relaxation and posi-

tive mood and a feeling of benevolence towards oneself and

others. Meditation by the Sahaja yoga technique is, according

to tradition, an innately therapeutic process which is

beneficial for all chronic diseases, mental or physical,

including asthma.

There are alternative explanations for the observed benefit.

Many yoga and meditation practices include exercises

designed to alter the pattern of breathing. Subjects in this

study were given no explicit instructions about controlling

their breathing pattern and we did not measure ventilation.

However, previous studies have shown that tidal volume and

frequency may be reduced during and following a period of

meditation.20 21 Mild hypoventilation has a number of physio-

logical consequences which could have affected our results.

Proponents of the Buteyko breathing technique claim that

asthma is associated with chronic hyperventilation and

consequent hypocapnia, and propose that exercises which

reduce minute ventilation are likely to be beneficial.22 In the

only published controlled trial of the Buteyko breathing

technique5 asthmatics receiving active treatment had signifi-

cant reductions in β2 agonist use, suggesting that the breath-

ing exercises reduced asthma symptoms. However, the

breathing exercises had no effect on end tidal carbon dioxide

pressure, suggesting that the mechanism of the effect is

unlikely to be via a reduction in hypocapnia.

An alternative hypothesis may be that altering the pattern

of breathing alters AHR by a direct effect on the dynamics of

airway smooth muscle. Recent observations have led to the

suggestion that the shortening velocity of airway smooth

muscle may be an important determinant of AHR.23 24 In addi-

tion, there is in vitro evidence which suggests that airway

smooth muscle shortening velocity may be affected directly by

the volume of tidal breathing.25 In this model, decreasing tidal

volume decreases the amplitude of force fluctuations acting on

the smooth muscle and leads to reductions in actin-myosin

crossbridge cycling rates and shortening velocity of the mus-

cle, with a subsequent reduction in the amount of airway nar-

rowing for a given stimulus. This model has not been tested in

humans but provides a plausible explanation whereby

changes in breathing pattern might alter AHR.

In conclusion, this randomised controlled trial has shown

that, in patients who express an interest in non-

pharmacological treatments for asthma, the practice of Sahaja

yoga does have limited beneficial effects on some objective and

subjective measures of the impact of asthma. Potential expla-

nations include an effect on the flow of “vital energy” accord-

ing to the traditional yogic system or an effect on airway

smooth muscle dynamics. While many will be sceptical of the

yogic explanation for these observations, it is possible that

further study of the effect of yogic meditation practices and

altered breathing patterns in subjects with asthma may eluci-

date new non-pharmacological strategies to assist in the con-

trol of the manifestations of this condition.

ACKNOWLEDGEMENTSThe authors gratefully acknowledge the assistance of Greg Turek,Peter Aerfeldt, Andrew Jones, Jelena Lemaic, Anne Stuckey, and Aly-son Roberts in conducting this study.

. . . . . . . . . . . . . . . . . . . . .Authors’ affiliationsR Manocha, Natural Therapies Unit, Royal Hospital for Women, NSW,AustraliaG B Marks, C M Salome, Institute of Respiratory Medicine, University ofSydney, NSW, AustraliaG B Marks, South Western Sydney Clinical School, University of NewSouth Wales, NSW, AustraliaP Kenchington, Concord Psychiatry Unit, NSW, Australia

Support: Royal Australasian College of General Practitioners (TraineeScholarship and Research Fund).

REFERENCES1 Groen J. The psychosomatic theory of bronchial asthma. Psychother

Psychosom 1979;31:38–48.2 Jones N, Kinsman R, Dirks J, et al. Psychological contributions to

chronicity in asthma: patient response styles influencing medical treatmentand its outcome. Med Care 1979;17:1103–18.

3 Ewer T, Stewart D. Improvement in bronchial hyper-responsiveness inpatients with moderate asthma after treatment with a hypnotic technique:a randomised controlled trial. BMJ 1986;293:1129–32.

4 Lehrer P, Hochron S, Mayne T, et al. Relaxation and music therapies forasthma among patients prestabilized on asthma medication. J BehavMed 1994;17:1–24.

5 Bowler SD, Green A, Mitchell CA. Buteyko breathing techniques inasthma: a blinded randomised controlled trial. Med J Aust1998;169:575–8.

6 Singh V, Wisniewski A, Britton J, et al. Effect of yoga breathingexercises (pranayama) on airway reactivity in subjects with asthma.Lancet 1990;335:1381–3.

7 Rai U, Wells B. Role of Sahaja yoga in asthma. In: XVI World Congresson diseases of the chest. Boston: 1989.

8 Woolcock A, Lundback B, Ringdal N, et al. Comparison of addition ofsalmeterol to inhaled steroids with doubling of the dose of inhaledsteroids. Am J Respir Crit Care Med 1996;153:1481–8.

9 Horwitz R, McGill K, Busse K. The role of leukotriene receptor modifiersin the treatment of asthma. Am J Respir Crit Care Med1998;157:1363–71.

10 Reddel H, Trevillion L, Salome C, et al. A scoring system for mild tosevere asthma. Aust NZ J Med 1995;25:423.

11 Browne WJ. Learning to unwind. A workbook on relaxation and stressmangement techniques. Sydney: Health Media and Education Centre,1984.

12 Marks G, Dunn S, Woolcock A. A scale for the measurement of qualityof life in adults with asthma. J Clin Epidemiol 1992;45:461–72.

13 McNair D, Lorr M, Droppleman L. POMS Manual - Profile Of MoodStates. San Diego, CA: EdITS/Educational and Industrial Testing Service,1992.

14 Quanjer P, Tammeling G, Cotes J, et al. Lung volumes and forcedventilatory flows. Eur Respir J 1993;6(suppl):5–40.

15 Yan K, Salome C, Woolcock A. Rapid method for measurement ofbronchial responsiveness. Thorax 1983;38:760–5.

16 Marks G, Dunn S, Woolcock A. An evaluation of an asthma quality oflife questionnaire as a measure of change in adults with asthma. J ClinEpidemiol 1993;46:1103–11.

17 Haahtela T, Jarvinen M, Kava T, et al. Comparison of a β2 agonist,terbutaline, with an inhaled corticosteroid, budesonide, in newly detectedasthma. N Engl J Med 1991;325:388–92.

18 Ernst E. Complementary therapies for asthma: what patients use. JAsthma 1998;35:667–71.

19 Ernst E. Breathing techniques: adjunctive treatment modalities forasthma? A systematic review. Eur Respir J 2000;15:969–72.

20 Sudsuang R, Chentanez V, Veluvan K. Effect of Buddhist meditation onserum cortisol and total protein levels, blood pressure, pulse rate, lungvolume and reaction time. Physiol Behav 1991;50:543–8.

21 Kesterson J, Clinch N. Metabolic rate, respiratory exchange ratio andapneas during meditation. Am J Physiol 1989;256:632–8.

22 Stalmatski A. Freedom from asthma: Buteyko’s revolutionary treatment.London: KyleCathie Ltd, 1997.

23 Solway J, Fredberg J. Perhaps airway smooth muscle dysfunctioncontributes to asthmatic bronchial hyperresponsiveness after all. Am JRespir Cell Mol Biol 1997;17:144–6.

24 Duguet A, Biyah K, Minshall E, et al. Bronchial responsiveness amonginbred mouse strains. Am J Respir Crit Care Med 2000;161:839–48.

25 Fredberg J, Inouye D, Mijailovich S, et al. Perturbed equilibrium ofmyosin binding in airway smooth muscle and its implication inbronchospasm. Am J Respir Crit Care Med 1999;159:959–67.


www.thoraxjnl.com

Sahaja yoga in asthmaSince the publication of our paper on Sahajayoga in the management of moderate tosevere asthma1 we have received a largenumber of enquiries. One issue that has beenraised about the technique used in the studywarrants clarification and further acknowl-edgement.

The Sahaja yoga meditation technique usedin the study was not developed by the authors.The technique was taught to subjects in theintervention group by experienced Sahajayoga practitioners free of charge. The tech-nique itself was developed by yoga expert H HShri Mataji Nirmala Devi and she permitted

the investigators to conduct the study on thefollowing reasonable conditions: (1) that nopart of the technique be misrepresented, mis-appropriated or commercialised by the inves-tigators; (2) that the founder and practition-ers of the process be appropriatelyacknowledged as the true source and custodi-ans of the technique and its associatedknowledge; and (3) that it be made clear thatthe Sahaja yoga technique is, as a matter ofpolicy and philosophical conviction, alwaysmade available free of charge.

The authors sincerely regret any misunder-standing that may have led readers ormembers of the public to believe otherwise.They sincerely and gratefully acknowledge

the important and crucial role played by HHShri Mataji Nirmala Devi and the Sahaja yogapractitioners of Australia in the execution ofthis study, and sincerely regret not havingmade more appropriate acknowledgements inthe original article.

R ManochaNatural Therapies Unit, Royal Hospital for Women,

Locked Bag 2000, Randwick 2031, Australia;[email protected]

Reference1 Manocha R, Marks GB, Kenchington P, et al.

Sahaja yoga in the management of moderateto severe asthma: a randomised controlledtrial. Thorax 2002;57:110–5.

Topics: 20; 46 Jrnl:thx Job:8 Div:tx310116Thorax 2003;58:00

www.thoraxjnl.com

A Pilot Study of a Mental Silence Form of Meditation for Womenin Perimenopause

Ramesh Manocha Æ Barbara Semmar ÆDeborah Black

� Springer Science+Business Media, LLC 2007

Abstract Menopausal symptoms often feature or are

worsened by psychological and psychosomatic factors. As

there is limited research into the potential role of psycho-

logical interventions, especially meditation, for the

treatment of these symptoms the current study adopted an

AB case series design with a follow-up phase. Fourteen

women who were experiencing hot flashes and other

menopausal symptoms and receiving no treatment for them

attended meditation classes twice weekly for 8 weeks and

practiced daily at home. A mental silence orientated tech-

nique of meditation called Sahaja Yoga (SYM) was taught.

The Hot Flash Diary, Kupperman Index, MENQOL,

Greene’s Climacteric Scale and STAI, were administered

at baseline, mid treatment (4 weeks), post-treatment

(8 weeks) and at 8 weeks follow-up. Substantial improve-

ments in all measures occurred at post treatment. Changes

in vasomotor symptoms, especially hot flashes, were most

prominent as a significant decrease of 67% at post-treat-

ment and 57% at follow-up (v2 = 11.7, p \ .003) were

noted and Kupperman’s Index score decreased by 58% at

post-treatment and 40% at follow-up (v2 = 11.7,

p \ .005). All other symptom measures improved sub-

stantially from baseline to post-treatment, non-parametric

analysis indicating that most of these changes were

significant. These findings tentatively suggest that meno-

pausal symptoms, especially vasomotor symptoms, and

particularly hot flashes, might be substantially improved by

using meditation.

Keywords Meditation � Hot flashes �Menopausal symptoms � Menopause � Mental silence �Sahaja Yoga � Behavior therapy

A total of 70% of women experience symptoms during

perimenopause (MacKinlay & Jeffreys, 1974), a period

which begins a few years prior to cessation of menstruation

and continues for some years afterwards, typically lasting

about 5 years. The most commonly-experienced meno-

pausal symptom is the hot flash, which can occur

unexpected and randomly. Hot flashes can be detrimental

to quality of life (Daly et al., 1993), are sometimes over-

whelming, and can affect social life, ability to work, sleep

patterns, and general perception of health (Greendale, Lee,

& Arriola, 1999; Roberts, Chambers, Blake, & Webber,

1992; Stein, Jacobsen, Hann, Greenberg, & Lyman, 2000).

Women with severe menopausal symptoms often seek

pharmacological management. The most widely-used

strategy is hormone replacement therapy (HRT). This is

effective, but many women are concerned about its

potential side effects (Hill, Weiss, & La Croix, 2000),

which can be short term, such as PV bleeding, or long term,

such as an increased risk of certain cancers. Recent revi-

sions to menopausal management guidelines (Women’s

Health Initiative Investigators, 2002) and associated media

attention has led to increased consumer interest in more

‘natural’ options. For instance, a North American Meno-

pause Society survey (1997) of women aged 45–60 found

R. Manocha (&)

Sydney Menopause Centre, Royal Hospital for Women, Sydney,

NSW 2031, Australia

e-mail: [email protected]

B. Semmar

Department of Psychology, Bond University, Brisbane, Australia

D. Black

Faculty of Medicine, School of Community Medicine,

University of New South Wales, Sydney, Australia

123

J Clin Psychol Med Settings

DOI 10.1007/s10880-007-9076-5

that 80% of respondents had used nonprescription thera-

pies to manage short-term disturbances or prevent long-

term consequences of menopause. Interest seems particu-

larly strong among women in whom HRT is

contraindicated, such as those with a history of breast

cancer (Newton, Buist, Keenan, Anderson, & LaCroix,

2002).

Simple lifestyle changes directed at modifying the

physiological environment can be effective. There is evi-

dence that regular exercise (Ivarsson, Spetz, & Hammar,

1998), elimination of smoking (Starapoli, Flaws, Bush, &

Moulton, 1998), and avoiding stress (Gannon, Hansel, &

Goodwin, 1987; Swartzman, Edelberg, & Kermann, 1990)

can reduce the impact of hot flashes. One study even

reported that hot flashes ceased immediately following

exposure to cold (Casper & Yen, 1985), implying that hot

flashes may be linked to irregular hypothalamic regulation

of core body temperature. Consequently, strategies such as

taking cold drinks, reducing the intake of spicy foods, and

providing room air circulation may be effective.

Complementary and alternative therapies include herbs,

vitamin and nutritional supplements, and behavior thera-

pies (Barton, Loprinzi, & Ko, 2002; Kronenberg & Fugh-

Berman, 2002). Behavioral therapies are particularly

attractive to both consumers and clinicians as they are non-

invasive and do not involve the consumption of exogenous

agents. As part of a preliminary assessment for an inter-

ventional study (described in further detail below), Hunter

and Liao (1995) surveyed menopausal women who were

seeking help for menopausal symptoms, and found that

60% of respondents preferred psychological treatment to

HRT. Their reasons included wanting to avoid the side

effects of HRT and use natural options while at the same

time gaining broader skills in managing stress and

enhancing self-efficacy.

Previous psychological treatments studied have inclu-

ded breathing exercises, relaxation (Freedman &

Woodward, 1992; Wijma, Melin, Nedstrand, & Hammar,

1997), cognitive behavioral therapy (Hunter & Liao,

1996), biofeedback, hypnosis (Younus, Simpson, Collins,

& Wang, 2003) and mindfulness meditation (Carmody,

Crawford, & Churchill, 2006). These studies are summa-

rized for the reader (see Table 1). In summary, change in

average hot flash frequency was quite variable, ranging

from 35% to 70%, and the degree and scope of changes in

ancillary symptoms also varied considerably.

Of particular relevance is the preliminary study by

Carmody in which mindfulness based stress reduction

(MBSR) was taught to 15 women. Participants experienced

a reduction of approximately 40% in the frequency of hot

flashes. Mindfulness meditation is a technique of medita-

tion that involves observation of thoughts and feelings, a

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123

practitioner calmer and less likely to engage in negative

thinking when faced with stressful events. MBSR includes

coaching in certain mental attitudes and beliefs about the

relationship between thoughts, feelings the mind and sense

of self and other exercises (Kabbat-Zinn, 1990). Questions

remain as to whether or not mindfulness is a meditation

technique, a relaxation method or a more complex form of

behavioral therapy. While meditation and relaxation are

overtly similar researchers such as Manocha, Marks,

Kenchington, Peters, and Salome (2002) provide empirical

evidence for a distinction between ‘‘classical’’ meditation

(with its emphasis on the mental silence experience), and

meditation as a method of relaxation and generic stress

management strategies. A separate assessment of the

clinical potential of mental silence orientated meditation is

therefore warranted.

This exploratory study examined the effects of SYM as

a management strategy for menopausal symptoms, partic-

ularly hot flashes using a ‘‘classical’’ definition of

meditation which features a state of ‘mental silence’ or

‘thoughtless awareness’ (Devi, 1997). Sahaja Yoga is a

technique that emphasizes the importance of this classical

approach and practitioners describe experiencing the state

of mental silence as a key part of the meditative experi-

ence. It can be characterized by the following features:

Elimination of unnecessary, especially negative thought

activity; focusing attention effortlessly on the ‘present

moment’ experience; and remaining alert and aware

(sometimes more aware, but not hyperactive) and in full

control of one’s faculties.

Method

A single cohort prospective, observational interventional

study using an AB design with a follow-up phase with

assessments at baseline, weeks 4, 8, and 16 was utilized.

Participants

Fourteen women with menopausal symptoms were enrolled

into a specifically-designed, 8-week-long instructional

program conducted at the Sydney Menopause Centre,

Royal Hospital for Women, Sydney, Australia.

Referrals were made by clinical staff at the Sydney

Menopause Centre of individuals who were attending the

center for assessment and treatment of menopausal symp-

toms. Inclusion/exclusion criteria for this trial were: last

menstrual period over 6 months prior; no other treatment,

alternative or conventional, for menopausal symptoms for

the past 8 weeks; no history of breast cancer; age between

40 and 60; no history of significant psychological or

physical illness; nonsmoker; and less than two standard

alcohol drinks per day. Subjects did not have a surgically/

medically induced menopause; or unwillingness to comply

with treatment guidelines of the study. Participants expe-

rienced a minimum of five hot flashes a day, as measured

by a hot flash diary.

Eighteen women originally agreed to be contacted by

the researcher. Four women were excluded because they

were unable to make the necessary commitment to attend

classes. Fourteen women gave informed consent and four

women dropped out before the end of the intervention

phase of the study and one woman was lost to follow-up.

Mean age was 55 years. Thirteen of the subjects were

either married or in defacto relationships.

The study was approved by the South Eastern Area

Health Service Ethics Committee.

Procedure and Measures

The meditation group attended the Sydney Menopause

Centre two evenings per week for 8 weeks where they

received structured classes on the practice of SYM. The

technique is based on a ‘‘classical’’ understanding of

meditation and uses a simple series of silent affirmations

based on a traditional understanding of yogic

psychophysiology.

The instructor was a health professional with expertise

in SYM instruction. Each instructional session lasted one

and a half hours. All participants began the program

simultaneously. Instructional audiotapes were given, as

well as written guidelines on how to cultivate the medita-

tion experience.

Each class began with an attendance role, followed by a

brief instructional talk on the principles of meditation to be

learned that day (focused on methodology such as breath-

ing techniques, attentional focusing skills and designed to

enhance the experience of mental silence), a question-and-

answer session on any difficulties participants were expe-

riencing, two guided meditation sessions separated by a

short break, and a second, brief question time.

Participants were introduced to the idea that most

menopausal symptoms could be spontaneously corrected

by the practice of regular meditation. The idea that the state

of mental silence was the crucial therapeutic component of

the experience was impressed upon them.

During meditation subjects were encouraged to sit qui-

etly in a chair or in a comfortable position that facilitated

their meditation experience. The instructional sessions

were specifically focused on helping participants achieve

the experience of ‘‘mental silence’’ and each week informal

feedback was sought by instructors regarding each partic-

ipants’ progress with regard to this. They were encouraged


123

to practice the techniques that they learned at home for

15 min twice each day.

Measures

At the first visit and at weeks 4, 8, and 16, participants

completed a battery of self-report questionnaires and a hot

flash diary:

• The Flash Count Diary requires that subjects tally each

hot flash as it occurred throughout a 7-day period

(Sloan et al., 2001).

• The Kupperman Index of Menopausal Symptoms, the

oldest menopausal self-report instrument, is a validated

menopause-specific symptom measure (Kupperman,

Blatt, Wiesbader, & Filler, 1953; Kupperman, Wetch-

ler, & Blatt, 1959) that focuses primarily on

symptomatic relief.

• The Menopause Specific Quality of Life Questionnaire

(MENQOL) is a validated questionnaire assessing the

impact of menopausal symptoms on quality of life and

is designed to detect changes as a result of treatment

(Hilditch et al., 1996).

• The State Trait Anxiety Inventory (STAI) has been

widely used in a variety of research settings and is one

of the most popular assessment tools used in research

into meditation (Spielberger, Gorsuch, & Lushene,

1968).

• The Greene’s Climacteric Scale is a self-report scale

measuring the severity of three common types of

menopausal symptoms: psychological, somatic, and

vasomotor (Greene, 1998).

Statistical Analysis

The most conservative approach in the handling of

missing values was taken, with no attempt being made to

estimate missing values, and each analysis used all

available scores.

Non-parametric analysis was the most appropriate way

to handle the data because of the small sample size. These

results are presented in Table 2. Response rates were

compared between pre-intervention, post-intervention, and

at follow-up to determine any change in hot flash fre-

quency. To facilitate discussion in this paper as well as

comparison with other studies Table 3 summarizes the

percentage change for each measure, between baseline and

post-intervention and baseline and follow-up.

Results

Vasomotor Symptoms

There was a clear improvement in vasomotor symptoms,

particularly hot flashes. Hot flash frequency is best assessed

by determining responder rate, with a reduction of 50% or

more regarded as a positive response (MacLennan, Lester,

& Moore, 2001). Eight out of ten participants exhibited a

positive response, and this response was maintained at

16 weeks follow-up. By post-treatment, hot flash frequency

was an average 67% below baseline, and at follow-up it

was still 57% below baseline. Non-parametric analysis of

hot flash frequency across the entire study showed that the

changes were significant.

Table 2 Non-parametric

repeated measures Friedman

test

Note: MENQOl, Menopause

Specific Quality of Life

Questionnaire; STAI, State Trait

Anxiety Inventory

Measure N Baseline Post-treatment Follow-up Friedman pMean rank Mean rank Mean rank v? (2df)

Hot flash frequency 10 2.89 1.50 1.61 11.7 .003

Kupperman Index 8 2.88 1.31 1.81 10.5 .005

Greene Climacteric Scale

Vasomotor 9 2.89 1.33 1.78 14.9 .001

Somatic 9 2.50 1.28 2.22 8.9 .012

Anxiety 9 2.67 1.22 2.11 10.1 .006

Psychometric 9 2.56 1.22 2.22 9.2 .010

Depression 9 2.33 1.50 2.17 4.7 .097

MENQOL

Vasomotor 9 2.28 1.72 2.00 1.5 .469

Psychosocial 9 2.33 1.11 2.56 10.9 .004

Physical 8 2.50 1.75 1.75 3.0 .223

Sexual 9 2.56 1.56 1.89 7.0 .030

STAI-state 10 2.50 1.80 1.70 4.0 .135

STAI-trait 10 2.50 1.60 1.90 4.4 .110


123

The Kupperman Index fell to a level 58% below base-

line, with only some loss of benefit at the follow-up

assessment, (compared to Wijma et al. (1997) average 43%

reduction in severity scores, which was however main-

tained at follow-up). Non-parametric analysis showed the

changes in the Kupperman’s Index to be significant.

Similarly, the vasomotor subscale of Greene’s Climac-

teric Scale improved an average 71% post-treatment. At

follow-up, scores returned to 53% below that of baseline.

Analysis of this subscale showed these changes to be sig-

nificant. The MENQOL’s vasomotor subscale scores were

53% better at post-treatment, and remained unchanged at

follow-up however on statistical analysis these changes

were not significant.

Informal feedback from participants indicated most

subjects did not continue meditating with the same inten-

sity after cessation of the program.

Other Symptoms and QOL Domains

Non-vasomotor symptom scores did not change as

impressively. For instance, the Psychometric and Depres-

sion subscales of the Greene’s Climacteric Scale and the

Physical subscale of the MENQOL, despite their impres-

sive changes at post-intervention were not maintained at

follow-up. Consequently, analysis showed that these

changes were not significant across the full duration of the

study.

Discussion

Notwithstanding the obvious limitations of this small,

uncontrolled trial those participants who completed the

program and were followed up appeared to experience

substantial improvements in a wide range of symptom-

atology. The most remarkable response was related to

vasomotor symptoms, particularly hot flashes. Analysis by

either frequency or responder rate indicated that the

improvement was both statistically and clinically signifi-

cant and more or less sustained even at the follow-up

phase. There was no significant change in frequency in the

follow-up phase, indicating that, even without professional

supervision and formal classes, participants were able to

maintain the health advantage that they achieved in the

formal phase of the treatment program.

Clinically significant improvements also occurred in a

number of the other measures, many of which were also

statistically significant. The Kupperman Index, the Vaso-

motor, Somatic and Anxiety subscales of the Greene’s

Climacteric Scale, the Psychosocial and Sexual subscales

of the MENQOL all exhibited statistically significant

changes across the entire assessment period. This is not to

say that the other changes seen in the other scales, such as

in both state and trait subscales of the STAI or the vaso-

motor subscale of the MENQOL, were negligible. In fact

Table 3 shows that the changes in these measures were

substantial however the power of the analysis is limited by

the small sample size. More fine grained analysis, say,

between baseline and post-intervention, was deemed

inappropriate given the small sample size and exploratory

nature of the study.

The loss of benefit indicated in some of the scales at

follow-up may be explained by reduced compliance in the

follow-up phase. By the same token, this also suggests that

even partial compliance with the treatment program may be

sufficient to maintain some benefits.

The improvements reported here compare favorably

with previous studies (see summary Table 1) suggesting

that the SYM approach may be more effective than a

simple relaxation approach, but may not necessarily be

more effective than multimodal approaches.

The mechanism of the menopausal hot flash is not yet

fully understood although a neuroendocrine pathway is

thought to have a primary role (Barton et al., 2002). It has

been proposed that a psychophysiological, neuroendocrine

pathway exists in which estrogen withdrawal leads to a

decrease in endorphin and catecholamine levels, which

culminates in increased hypothalamic norepinephrine and

serotonin release. The change in these two factors then

lowers the set point in the thermoregulatory nucleus of

the brain: heat loss mechanisms are triggered and con-

sequent increases in peripheral blood flow remove heat

Table 3 Descriptive summary of changes, baseline to post-inter-

vention, to follow-up

Measure Post-intervention Follow-up

% Change % Change

Hot flush frequency 67.2 56.2

Kupperman Index 58.2 40.4

Greene Climacteric Scale

Vasomotor 71.1 52.4

Somatic 80.8 29.3

Anxiety 77.5 32.9

Psychometric 74.3 21.4

Depression 69.1 2.1

MENQOL

Vasomotor 46.7 46.7

Psychosocial 45.9 37.2

Physical 53.0 31.7

Sexual 56.2 33.3

STAI-state 25.8 26.6

STAI-trait 26.4 23.0

Note: MENQOl, Menopause Specific Quality of Life Questionnaire;

STAI, State Trait Anxiety Inventory


123

from the body, producing both a hot flash and associated

vasomotor phenomena (Shanafelt, Barton, Adjei, & Lop-

rinzi, 2002).

Consequently, SYM may be helpful in mitigating the

experience of hot flashes via a number of possible path-

ways. Studies in the area have implicated the stress

response via reduction in physiological arousal (Panjwani,

Gupta, Singh, Selvamurthy, & Rai, 1995), creation of a

change in the levels of circulating stress hormones

(Panjwani et al., 1995) or in reductions in cortisol

releasing factor (Harte, Eifert, & Smith, 1995). However,

Swartzman et al. (1990) in a study on stress-induced hot

flashes, suggested simple reduction in arousal may not be

the only explanation. Using objective measurements,

these researchers found menopausal women exposed to

various experimental stressors experienced more frequent

and more distressing symptoms, but the additional hot

flashes did not occur during stress and were not associated

with elevated sympathetic arousal. This suggests the

effects may be mediated by a slower neuroendocrine

pathway other than the sympathoadrenal axis which sup-

ports the stress response. For example, stress and,

inversely, stress reduction may alter hypothalamic release

of estrogen, which in turn changes the firing threshold of

hypothalamic thermoregulatory neurons. The negative

emotions of stress are processed in the limbic system, and

some experiments involving stimulation of the hippo-

campus have been shown to change thermosensitivity of

preoptic neurons (Shanafelt et al., 2002). This might

explain why stress potentiates rather than precipitates hot

flashes and why meditation might be effective not only in

reducing the severity of hot flashes but also preventing

them.

From a psychobehavioral perspective Borkovec et al.

(1987), and many others have found that CBT leads to a

reduction in the physiological and psychological elements

of anxiety in normal populations and clinical populations.

However, in the present study, more robust effects were

observed in scales assessing physical symptoms rather than

psychological ones. This suggests that SYM’s primary

effect was via alteration of physiological function rather

than cognition and that the significant changes in psycho-

logical measures may be a consequence secondary to

changes in physiological activity.

The small sample size in the current study means small,

but real, treatment effects may not have been identified.

This may explain why some changes in psychological

measures, such as that seen in the vasomotor scale of the

MENQOL, failed to reach significance in the non-para-

metric analysis despite their impressive numerical changes

and the clinical improvements that they imply. Further

studies using larger samples are needed to more fully

explore this.

Of the14 participants for whom baseline measures were

taken, only 10 continued with the study. Selection bias may,

therefore, have inflated the apparent effect of the interven-

tion. Selection bias is especially important in studies such as

this which involve intense commitment from participants

and hence considerable expectation of benefit as well as

selection through attrition of those that are experiencing

positive outcomes. On the other hand, our drop out rate is

similar to that seen in many other lifestyle modification

studies, and similar rates would probably be seen in real life.

Furthermore, while the drop-out phenomenon introduces

bias by selecting for those most motivated, or those expe-

riencing most benefit, it also allows researchers to look at

the efficacy of such treatments in those participants most

likely to try them in the community.

The absence of a control group makes it difficult to

identify the magnitude of nonspecific factors, such as the

placebo effect, expectancy, demand, practice effect, and

regression to the mean. It is well recognized that these

phenomena can have potent effects in psychophysiological

symptoms such as the vasomotor phenomena associated

with the perimenopause; for example, flashing responds to

suggestions of improvement (Clayden, Bell, & Pollard,

1974). A number of reviews have suggested that placebo

effect can be substantial for vasomotor symptoms

(Shanafelt et al., 2002). MacLennan et al. (2001) sys-

tematic review of estrogen versus placebo effects for the

management of menopausal symptoms found that, while

HRT was clearly more effective than placebo, subjects in

the placebo groups experienced up to 50% improvement

in hot flash frequency from baseline to the end of the

study.

In our study, the responder rate was 80%, and the mean

reduction in hot flashes was 67%. This suggests that the

observed effect is unlikely to be due to placebo or other

nonspecific factors alone. The fact that hot flashes, com-

pared with affective phenomena such as anxiety or

depression, improved to a greater degree supports the idea

that the observed effect is not simply due to a change in

subjective perception. Similarly, while it is possible that

participants may have experienced an unrelated, sponta-

neous improvement as part of the condition’s natural

history, the usual time span for such regression to the mean

is several years, whereas the improvements in this study

occurred over several weeks and were maintained for some

months afterwards.

The improvements in the psychological dimensions are

consistent with effect magnitudes seen in studies using

CBT or other psychotherapy, although our intervention did

not include any formal counseling. A number of studies

clearly suggest that meditation can have an effect similar to

(West, 1987) or greater than (Manocha et al., 2002) that of

other behavioral techniques. There is also some evidence to


123

suggest that the effect of meditation, and some other

behavior therapies, extends beyond subjective experience

and into the physical parameters of illness itself (Manocha

et al., 2002).

Carmody et al.’s (2006) study which used mindfulness

meditation reported similar levels of completion by par-

ticipants but considerably smaller effects on hot flash

frequency (35% at the end of the intervention period and

45% at the follow-up phase). The apparently larger

response observed in our study may be due to the funda-

mental differences between the two approaches vis a vis

the emphasis on mental silence in the SYM technique

versus the emphasis on mental observation in the MBSR.

The comparative effects of these two approaches warrant

further investigation.

Admittedly, the heuristic nature of this study has its

limitations. But its value is significant because, first, it

suggests that a potent effect may be available from an

easily learned behavioral method. Second, this method is

concerned with a relatively unique idea that the meditative

‘‘state of consciousness’’ is responsible for its therapeutic

effect. Third, no other behavioral method has explicitly

connected this notion with health outcomes and yet the

apparent magnitude of effect is one of the largest so far

reported in the literature. Fourth, other RCTs of the same

method suggest that this conceptual approach to medita-

tion, unlike other approaches, is yielding evidence of

specific effects. Therefore this study is not only significant

to clinicians looking for promising behavioral therapies but

will also be useful to those researchers looking for ways to

understand and study meditation.

In conclusion, this preliminary assessment of meditation

for menopausal hot flashes and other menopausal symp-

toms showed SYM has demonstrated promising effects.

These effects seem comparable if not possibly greater than

that seen in studies of other behavior therapies. Further

investigation is needed using RCT methodology with

adequate sample size and proper strategies to control for

non-specific effects associated with behavior therapies to

determine whether or not these effects are real and specific

to this particular intervention. As demand from consumers

for information on non-pharmacological approaches to

controlling menopausal symptoms increases, the impera-

tive for such exploration grows.

Acknowledgements The authors gratefully thank the Sydney

Menopause Centre, Royal Hospital for Women, Dr Greg Turek and

Mr Robert Hutcheon, Sahaja Yoga instructors and the Sahaja Yoga

practitioners of Sydney who offered their support without charge. The

authors also acknowledge the founder of the modern Sahaja Yoga

technique, Shri Mataji Nirmala Devi, who permits its use in scientific

research on the proviso that it not be commercialized. The authors did

not develop the Sahaja Yoga method and declare that they have no

financial conflict of interest in this study.

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http://www.menopause.org/surveys/97survey.html

Sahaja Yoga Meditation as a Family TreatmentProgramme for Children with Attention

Deficit-Hyperactivity Disorder

LINDA J . HARRISONCharles Sturt University, Australia

RAMESH MANOCHAUniversity of New South Wales, Australia

KATYA RUBIAInstitute of Psychiatry, King’s College, London, UK

A B S T R AC T

The use of complementary and alternative medicine (CAM) as a treatment forchildren diagnosed with attention deficit-hyperactivity disorder (ADHD) is wide-spread, but little is known on the effectiveness of many such therapies. This studyinvestigated meditation as a family treatment method for children with ADHD,using the techniques of Sahaja Yoga Meditation (SYM). Parents and childrenparticipated in a 6-week programme of twice-weekly clinic sessions and regularmeditation at home. Pre- and post-treatment assessments included parent ratingsof children’s ADHD symptoms, self-esteem and child–parent relationship quality.Perceptions of the programme were collected via parent questionnaires and childinterviews. Results showed improvements in children’s ADHD behaviour, self-esteem and relationship quality. Children described benefits at home (better sleeppatterns, less anxiety) and at school (more able to concentrate, less conflict).Parents reported feeling happier, less stressed and more able to manage theirchild’s behaviour. Indications from this preliminary investigation are that SYMmay offer families an effective management tool for family-oriented treatment ofchildhood ADHD.

K E Y WO R D S

attention deficit-hyperactivity disorder (ADHD), child–parent relationships,complementary and alternative medicine (CAM), meditation

T H E M O S T C O M M O N LY used treatment for attention deficit-hyperactivity disorder(ADHD) in North America and Australia continues to be psycho-stimulant medication(Goldman, Genel, Bezman, & Slanetz, 1998; Rubia & Smith, 2001; Vance & Luk, 2000),which has been found to improve the core behavioural and cognitive features of ADHD,

Clinical Child Psychology and Psychiatry 1359–1045 (200410)9:4 Copyright © 2004SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 9(4): 479–497;

DOI: 10.1177/1359104504046155 www.sagepublications.com

479

www.sagepublications.com

such as behavioural inhibition and concentration, as well as co-morbid symptoms suchas poor academic achievement, in about 80% of the children (Barkley, 1997; Cara, 2002;Gage & Wilson, 2000). In the last 10 years, a five-fold increase in methylphenidateprescription and consumption has been seen, with as many as 30–40% of children insome American schools receiving stimulant medication (Ghodse, 1999). Similar trendshave been seen in Australia. From 1990 to 2000, the rate of children receiving stimulantmedication for ADHD increased in the order of nine times (Committee on Children andYoung People, 2002). This, among other factors, has made community concerns aboutpossible over-prescription and side effects of methylphenidate grow (Vimpani, 1997).Common physiological short-term side effects of stimulant medication are insomnia,appetite loss, stomach-aches, dizziness and daytime drowsiness, in addition to emotionaland motor symptoms, such as mood lability and tics (Vance & Luk, 2000). In addition,

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AC K N O W L E D G E M E N T S : The authors gratefully acknowledge the contribution of AliceBhasale, Robert Hutcheon, Kim Pearce, Liallyn Fitzpatrick, Ione Docherty and other SahajaYoga instructors who provided training for the participants on a voluntary basis. Sarah Yates’help with data entry is gratefully acknowledged. We also thank the Royal Hospital forWomen, University of New South Wales, for providing facilities for running the meditationclinic. Importantly, we thank the developer of Sahaja Yoga meditation, Mrs NirmalaShrivastava (Shri Mataji Nirmala Devi), for her advice and permission to evaluate her tech-nique. We acknowledge that, as a matter of principle, Sahaja Yoga is always taught free ofcharge.

L I N DA H A R R I S O N is a Senior Lecturer in the School of Teacher Education, Charles SturtUniversity, where she teaches child development and early childhood practice. Her researchhas focused on children’s attachment relationships with parents and teachers and how theseexplain socio-emotional adjustment over time. Currently involved in the design andimplementation of large research projects investigating family and childcare predictors ofchildren’s development, health and well-being, including the Longitudinal Study ofAustralian Children, the Sydney Family Development Project and the New South Wales ChildCare Choices study.

R A M E S H M A N O C H A is a general practitioner and researcher who currently holds the BarryWren Research Fellowship at the Royal Hospital for Women and the School of Women’s andChildren’s Health, Faculty of Medicine, University of New South Wales, Sydney, Australiawhere he is involved in scientific evaluation of complementary and alternative medicines. In1998 he established the Meditation Research Programme (MRP). Since that time, the MRPhas conducted exploratory clinics, physiological evaluations and several high-qualityrandomized controlled trials. In 2002 the MRP was approached by members of thecommunity to explore the potential of Sahaja Yoga meditation for children with ADHD andthus the ‘Meditation for ADHD Clinic’ was initiated. Dr Manocha is a recipient of theBernard Lake Memorial Prize for complementary medicine research.

C O N TAC T: Natural Therapies Unit, Royal Hospital for Women, Locked Bag 2000,Randwick, NSW 2031, Australia. E-mail: [email protected]

K AT YA R U B I A is a Senior Lecturer in Cognitive Neuroscience in the Dept of ChildPsychiatry, Institute of Psychiatry, King’s College, London. Her work has focused on thecognitive neuroscience of executive and attention functions and in determining the neuro-biological basis of ADHD by use of functional magnetic resonance imaging (fMRI). She iscurrently investigating the specificity of the neurobiological basis of executive dysfunctions inmajor developmental disorders such as ADHD, conduct disorder, obsessive-compulsivedisorder, depression and autism.

psycho-stimulants can produce abuse and dependency (Goldman et al., 1998) and thepotential long-term side effects of lengthy treatments are not known (National Instituteof Mental Health, 1998; Schachar & Tannock, 1993). As such information becomes morewidely available to the public, it is not surprising that large numbers of parents seekcomplementary and alternative medicine (CAM) therapies (Chan, Rappaport, &Kemper, 2003; Stubberfield & Parry, 1999) as a response to their ‘concern about thephysiological and psychological effects that the drugs may have on their children’ (Rice& Richmond, 1997, p. 93). Support for CAM has also come from clinicians who arguethat an emphasis on medical therapy alone draws attention to the control of symptoms,rather than attending to the need for children to acquire important behavioural andsocial skills (Zametkin & Ernst, 1999).

The issue of community concern relating to the escalating use of stimulants in themanagement of ADHD symptoms, treatment acceptability, side effects, potential long-term effects, danger of drug abuse and dependency, and consumer and parent prefer-ence of non-pharmacological treatment, compels researchers to explore other treatmentoptions. According to Rice and Richmond (1997), the most promising interventions arethose that work with the whole family system and use medication in association with non-medical interventions. Non-medical interventions for ADHD include a variety of behav-ioural treatments, such as cognitive-behaviour therapy, as well as complementary andalternative treatments, such as dietary modification, biofeedback, relaxation training andmeditation (for reviews of CAM and ADHD see Arnold, 2001; Chan, 2002; Pelham,Wheeler, & Chronis, 1998). Arnold’s review of alternative approaches to the manage-ment of ADHD noted that meditation was one of a number of promising strategies andwarranted further systematic assessment. However, to date there have been only twounpublished dissertations suggesting that meditation may improve impulsiveness athome and in the classroom in children with ADHD (Arnold, 2001).

Meditation is classified by Chan (2002) as one of a number of ‘lifestyle/mind–body ther-apies,’ which elicit the relaxation response and reduce hyperarousal to stress. Reviewstend to present meditation and relaxation training methods conjointly (Canter, 2003;Chan, 2002); however, some authors see meditation as different to relaxation. Forexample, Manocha, Marks, Kenchington, Peters, and Salome (2002) describe meditationas a self-management strategy for acquiring personal awareness and self-control.Although meditation may not be well understood or defined by western therapeuticmodels, the eastern definition is very clear: Meditation is a state of ‘mental silence’ charac-terized by the elimination of unnecessary thought, effortless attention on the presentmoment and alert awareness (Srivastava, 1997). There are many different meditationtechniques currently taught in the west, including ‘listening to the breath, repeating amantra, or detaching from the thought process, to focus the attention and bring about astate of self awareness and inner calm’ (Canter, 2003, p. 1049). Of these, Sahaja YogaMeditation (SYM), which is based on scientific principles introduced by the founder, ShriMataji Nirmala Devi Srivastava, has shown promise in a number of clinical trials. SYMclaims to relax the sympathetic nervous system by activating parasympathetic–limbicpathways that relax body and mind (Srivastava, 1997). Clinical treatment studies of SYMhave reported physiological and psychological benefits for patients with asthma(Manocha et al., 2002), stress disorders (Rai, Setji, & Singh, 1988), depression (Morgan,2001) and epilepsy (Panjwani, Gupta, Singh, Slevamurthy, & Rau, 1995; Panjwani et al.,1996; Yardi, 2001). Direct physiological effects of SYM include indicators of increasedparasympathetic activity such as a decrease in blood pressure, decreases in heart, respi-ratory and pulse rates, and an increase in galvanic skin resistance (indicator of decreasedsympathetic activity) (Rai et al., 1988). In electrophysiological investigations, SYM has

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been associated with reduced complexity of electroencephalogram (EEG) patterns andincreases in the medium frequency and low-beta ranges suggestive of increased atten-tional control (Aftanas & Golocheikine, 2001, 2002). Alteration in beta/theta waves bymeans of biofeedback, however, has been shown to correlate with improvement inADHD symptoms (for an overview see Ramirez, Desantis, & Opler, 2001). It is thuspossible that the mechanisms of action of yoga meditation resemble theta/beta biofeed-back techniques by enhancing overall alertness, attentional focus and relaxation. Thisbackground of neurological, physiological and psychological research, as well as thepractical experience of teachers and yoga practitioners who have noted that SYM helpsto focus attention, enhance concentration and memory, and improve children’s perform-ance at school (Srivastava, 1997), suggests that SYM is a useful alternative treatment forchildren with ADHD.

Core symptoms of childhood ADHD, according to the DSM-IV (American Psychi-atric Association, 1994), are inattention, impulsivity and hyperactivity. Associatedsymptoms are academic underachievement and impaired self-esteem (Cara, 2002;Treuting & Hinshaw, 2001). The typical pattern is thus one of a highly energetic, impul-sive, delay-aversed, unfocused and behaviourally poorly controlled child who demandsconstant attention and redirection. The central problem of the disorder is difficulty inself-regulating own behaviour (Anderson, 1997; Barkley, 1997; Rubia et al., 2001). Struc-tural studies have related ADHD to abnormalities in the frontal cortex and the basalganglia (Castellanos et al., 2002). Electrophysiological studies have pointed to functionaldeficits in the brain as correlates of poor regulatory control in hyperactive children (e.g.Barry, Clarke, & Johnstone, 2003; Barry, Johnstone & Clarke, 2003) and modern func-tional imaging studies have associated abnormal activation of frontal brain areas withdeficits of inhibitory and attentional control (Rubia et al., 1999, 2001; Vaidya et al., 1998).Neurotransmitter abnormalities, such as dopamine dysregulation, have also been linkedto ADHD (reviewed in Rubia & Smith, 2001); notably, dopamine transporter (DAT)levels are elevated in the striatum of children (Cheon et al., 2003) and adults with ADHD(Krause, Dresel, Krause, Kung, & Tatsch, 2000).

In considering a psychological aetiology of this disorder, authors have looked to trans-actional models that explain poor self-regulatory behaviour within the wider context offamily dynamics and parent–child relationships. Certainly, research shows that an ADHDchild may unduly strain these relationships. Cara (2002) notes that parents often feel frus-trated, anxious and angry that parenting techniques effective for other children appearuseless in the child with ADHD, who seems not to understand the consequences ofinappropriate behaviour or to learn from punishment. When oppositional, non-compliantbehaviour is characteristic, parents may be less appreciative of their children’s efforts, lesswilling to reward them, and more negative, directive and controlling (Rice & Richmond,1997). An alternate interpretation suggests that deficits in self-regulation may be relatedto insecure parent–child attachment relationships (Olson, 1996; Steifel, 1997), which arecharacterized by a pattern of conflicted, angry parent–child interchanges (Bowlby,1969/1982). To date, few studies have examined attachment status in children with ADHD.Researchers in New Zealand have reported that maternal responsiveness and synchron-ous interaction (which are known predictors of attachment security, e.g. de Wolff & vanIJzendoorn, 1997) were significantly lower in ADHD mother–child dyads than in amatched control group (Keown & Woodward, 2002). In Australia, Clark, Ungerer,Chahoud, Johnson, and Stiefel (2002) noted consistent associations with insecurity inchildren with ADHD across three different representational assessments of attachment.ADHD was linked to heightened emotional expression and out-of-control affects, suggest-ing an insecure–ambivalent or disorganized attachment relationship with the parent.


482

We sought to assess the contribution of Sahaja Yoga Meditation (SYM) to a moreeffective management of the main problems experienced by children with ADHD, suchas stability of attention and concentration, motor activity, problems of inhibition andeasily frustrated mood, as well as associated problems such as poor self-esteem and diffi-culties at school. By presenting SYM as a family practice and encouraging parents tomeditate regularly with their child, we sought to assess the extent of individual benefitsfor parents as well as any improvement in the security of the parent–child relationship.It was expected that SYM would be an adjunct to children’s on-going medical therapyand would provide a means of working with the whole family. The aims of theprogramme reflected the goals for appropriate treatment identified by the AmericanAcademy of Pediatrics (Cara, 2002); that is, to improve core symptoms of ADHD,reduce associated symptoms and improve functional outcomes. These aims were testedin a voluntary clinic provided at the Royal Hospital for Women, Sydney, Australia withthe help of a team of experienced instructors in SYM.

Method

RecruitmentThe SYM trial treatment programme was approved by the Human Ethics Committee ofthe South Eastern Sydney Area Health Service. The programme was publicized by anewspaper article and an introductory lecture, which was open to parents of school-agechildren with ADHD. Interested parents were invited to participate with their child ina 6-week programme of twice-weekly sessions teaching SYM as a potential non-drugadjunctive intervention for children with ADHD. Inclusion criteria were that the childhad a formal diagnosis of ADHD, that is, met the DSM-IV criteria made by a paedia-trician or child psychiatrist (National Health and Medical Research Council, 1996).Although it was clear from comments made by a number of parents at the recruitmentsession that they were looking for alternatives to medication, at no point in the SYMprogramme were parents advised or asked to reduce their child’s pharmacological treat-ment for ADHD. The introductory session, information sheet and discussions withparents during the programme made no recommendations about medication, except thatparents should monitor and adjust their children’s medication as they normally would,in conjunction with their doctor or psychologist. Parents gave written consent for them-selves and their child to participate.

ParticipantsGeneral information on the children’s age, diagnosis of ADHD and medication wascollected prior to the commencement of the meditation training, along with parent-reported ADHD symptoms. Only those children who scored above threshold for ADHDwere included in the study (i.e. a score of 15 and over on the Conners Parent–TeacherQuestionnaire; see later). Forty-eight children (41 boys, 7 girls), including four sets ofsiblings, met the criteria for inclusion in the programme. The majority of children(n = 31) were receiving medication (e.g. ritalin, dexamphetamine), 14 were notmedicated, and medication information was not provided for the other 3 children.Demographic information showed that families represented a diverse population. Aboutthree-quarters of the 44 families were in couple relationships and one-quarter comprisedsingle parents or guardians. Adult participants who provided personal data included 38mothers, 22 fathers and 1 grandmother. Mothers ranged in age from 27 to 50 years(M = 38.8, SD = 5.9); fathers were slightly older than mothers (range: 35–55 years,M = 43.1, SD = 5.2). Education levels for both mothers and fathers ranged from less than


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secondary school to doctoral studies, with the majority having completed tertiary levelstudies (mothers, 62%; fathers, 73%). Parent ethnicity was less diverse: 95% of partici-pants identified themselves as white/Caucasian.

Because of the requirement for personalized training in the SYM programme, it wasnecessary to separate the children into two groups and run two sequential treatmentprogrammes. Group 1 comprised older children (19 boys, 1 girl) and their parents (agerange: 8–12 years, M = 10.09, SD = 1.13). There was also a 6-year-old female sibling whowas included in this group. The group 1 treatment programme began at the end of thesummer holidays and continued into the first term of school. Children in group 2 weremore diverse in age (range: 4–12 years, M = 7.4 years, SD = 2.0). Participants included15 ‘waiting list’ children whose parents attended the initial recruitment session, and afurther 12 children whose parents joined at the commencement of the secondprogramme.1 Group 2 treatment began during the Easter school holidays and continuedinto the second school term.

Sahaja Yoga Meditation programmeThe intervention programmes were conducted over a 6-week period, using Sahaja YogaMeditation (SYM) techniques developed and described by Shri Mataji Nirmala DeviSrivastava (n.d.). SYM uses a simple meditation method that can be easily taught tochildren and adults. The treatment programme consisted of twice-weekly 90-minuteclinics, held in large meetings rooms at the hospital. For the first 3 weeks, the clinicconsisted of guided meditation sessions, with parents attending one group and thechildren another. The meditation process involved practising techniques wherebyparticipants were helped to achieve a state of thoughtless awareness. Instructors directedparticipants to become aware of this state within themselves by becoming silent andfocusing their attention inside. Parents were also asked to conduct shorter meditationsessions at home twice a day.

In the clinic, there were usually two periods of meditation of 5–15 minutes each,supplemented by information about how to meditate and sharing of experiences. Theparent sessions had one to two instructors, but the child sessions had a higher instruc-tor-to-child ratio (normally, one instructor for every three children). From week 4 toweek 6, one of the weekly sessions was conducted as a joint parent–child meditation.This enabled instructors to train parents in guiding their child’s meditation. Children andparents were asked to meditate regularly at home and to record their progress in a diary,which was checked each week to encourage compliance.

Assessment proceduresChildren and parents contributed to a range of data collection procedures, which drewon three sources: child self-report questionnaires, parent-rated questionnaires andexaminer testing and interviews. Assessments were conducted at three points: recruit-ment or commencement of the meditation programme (week 1), midway point of theprogramme (week 3) and the end of the programme (week 6). The full schedule ofassessments was completed for group 1. The second treatment programme, group 2, usedfewer measures and assessments were only completed at the commencement (week 1)and end of the programme (week 6).

Child assessment measures: Parent report

Conners Parent–Teacher Questionnaire ADHD symptoms were assessed via parentreport, using the Conners Parent–Teacher Questionnaire (National Institute of Mental


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Health, n.d.). Conners parent-rated checklists, which are shorter versions of the 93-itemoriginal, are commonly used tools in research and clinical practice (reviewed in Conners,Sitarenios, Parker, & Epstein, 1998). The measure chosen for our study presents 10behavioural descriptors (e.g. excitable/impulsive; fails to finish things/short attentionspan) that parents rate on a 4-point scale (0 = not at all, 1 = just a little, 2 = pretty much,3 = very much), and one overall question ‘How serious a problem do you think the childhas at this time?’ (0 = none, 1 = minor, 2 = moderate, 3 = severe). These 11 items achieveda high level of internal reliability. Coefficient alphas ranged from .74 to .86. Ratings onthe 11 items were summed to give a total score for ADHD symptoms at each assessmentpoint (possible range 0–33).

Perceived outcomes of SYM for the child At the mid- and endpoints of the programme,parents were asked to complete a short questionnaire asking whether they felt the medi-tation had benefited the child, and whether it had made a change to the relationship theyhad with the child. Simple 5-point rating scales were used to obtain information on thelevel of benefit (1 = little; 5 = a lot) for the child in the areas of emotions (anxiety, anger,able to manage negative feelings), self-esteem (confidence), attention (memory, able tosettle down) and sleep. Additional questions were included at the final point aboutbenefits for the child’s schoolwork, e.g. positive attitudes about going to school, socialrelations with the teacher and other children, and attention to schoolwork and homework.

Psycho-stimulant medication At the mid- and endpoints of the programme, parents wereasked about any changes they may have made to their child’s level of medication. Thequestion asked was ‘have you been able to reduce your child’s level of medication andstill maintain an acceptable level of behaviour?’ If medication had been reduced, parentswere asked to report the proportion; that is, less than half, half or more than half.

Biobehavioural Indicators of Self-Esteem We used Burnett’s (1998) 13-item BiobehaviouralIndicators of Self-Esteem questionnaire, which asks parents to rate their child’s behav-iour over the previous 2 weeks on a 5-point scale. Statements assess social interaction,confidence and involvement. Internal consistency was high; alphas ranged from .81 to.94. Ratings were combined to give a mean score for indicators of self-esteem.

Child assessment measures: Child self-report

Burnett Self-Scale An abbreviated version of Burnett’s (1994) 40-item self-evaluationand self-description measure was used to assess child self-esteem. For the present study,only the areas of peer relations, relations with mother and father, and learning self-concept were selected. Internal consistency of the modified scale was high; coefficientalpha = .95.

Child assessment measures: Examiner testing and interviews

Peabody Picture Vocabulary Test – Third edition Cognitive ability was assessed using thePeabody Picture Vocabulary Test – Third edition (PPVT-III; Dunn & Dunn, 1997). ThePPVT measures receptive language and has been shown to provide a good measure ofverbal comprehension and to correlate highly with measures of academic performance.

Child interviews Audio-taped interviews were conducted individually with children atthe end of the 6-week meditation programme. Questions focused on the children’s


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experience of the meditation programme, whether they liked meditation, what they likedabout it, whether they felt it had helped them and how it had helped.

Parent assessment measures

Perceived outcomes of SYM for the parent Parents were asked to report on their ownexperiences of the meditation programme and whether they felt it had been beneficialto them, by rating the extent to which they felt happier, less stressed, more able tomanage stress, less angry and more able to manage anger on a 5-point rating scale (1 =little benefit, 5 = a lot of benefit). At the end of the programme, parents were also askedto provide written examples of recent positive and negative interactions with their child.

Child–Parent Relationship Scale Parents completed the 30-item Child–Parent Relation-ship Scale (CPRS), which assesses the quality of the parent–child relationship. TheCPRS is an adaptation of Pianta’s (1990) Student–Teacher Relationship Scale, which hasbeen used extensively in studies of relationship quality in Australia (Harrison et al., 2003)and the US (National Institute of Child Health and Development Early Child CareResearch Network, n.d.; Pianta & Steinberg, 1992). Items on the CPRS tap four dimen-sions of child–parent attachment, warmth, conflict, dependence and open communi-cation, on a 5-point rated scale. Internal consistency for the total scale score was high,coefficient alpha = .84 and .86 at weeks 1 and 6, respectively.

Results

Results are presented in four sections. First, children’s baseline ADHD data aredescribed in relation to family demographic characteristics. This section also reportsSYM programme retention and completion rates for the two treatment programmes, andbaseline ADHD data for ‘waiting list’ children. Second, the impact of SYM on changesin ADHD symptoms, along with medication status and perceived child outcomes areexamined. In the third section, SYM effects are examined in relation to a wider range ofpsychological assessments, including cognitive ability, self-esteem and parent–childrelationship quality. Finally, results of the SYM programme for parent participants arepresented. Because of the small sample size, analyses were descriptive; t-tests were usedfor group comparisons.

Baseline ADHD symptoms: Demographic factorsData from parent reports at the initial recruitment or commencement stage of the SYMprogramme showed that children’s baseline ADHD symptoms were moderately high(M = 22.65), and varied across the 48 participants (SD = 4.36; range: 15–30). Initialcomparison of means, using t-test analysis, showed that there were no differences inbaseline ADHD symptoms for children allocated to group 1 vs group 2 (Ms = 23.00 and22.37, respectively, t = .24, ns) or for boys vs girls (Ms = 22.59 and 23.00, respectively,t =.05, ns). Children from couple families had significantly lower ADHD symptom scores(M = 21.25, SD = 3.88) than children from single-parent families (M = 25.58, SD = 3.68,t = 11.19, p < .01). Children whose parents had completed tertiary education had lowerscores (M = 21.23, SD = 4.34) than the children of non-tertiary educated parents(M = 24.13, SD = 4.09, t = 5.17, p < .05).

Retention rates for the two 6-week SYM programmes were reasonably good,especially considering that many families travelled long distances to attend the hospitalclinic and that children attended outside-school activities that competed with the clinic


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times and home meditation expectations. For group 1, 16 of 21 children completed thefull 6-week programme – a retention rate of 76%. For group 2, 19 of 27 childrencompleted the treatment – 70% retention. Unfortunately, owing to organizationalproblems in the final week, endpoint data were provided by only 10 of the 19 group 2children. Therefore, the combined studies provided pre- and post-treatment data for 26children. Comparisons of mean ADHD scores, using t-test, showed that there were nodifferences between the participants who provided complete data (N = 26) and thosewho did not (N = 22), on any of the demographic measures (child’s age and sex, mother’sand father’s age and education, family marital status) or in the proportion of childrenreceiving medication.

The sequential administration of the SYM programme provided an opportunity toassess baseline ADHD symptoms for children who were placed on the ‘waiting list’ ontwo occasions prior to treatment – at the initial recruitment stage and several monthslater at the commencement of the second programme. These children provided a quasi-control group for group 1 children, in that they did not receive treatment during the firstsession. Analyses using correlation and comparison of means tests showed that children’sADHD scores were consistent across these two occasions, r(12) = .68, p = .015, and hadremained at a similar level (M1 = 22.08, SD = 4.72; M2 = 21.17, SD = 4.69; t = .84, ns).

Change to ADHD-related symptoms: Pre- and post-SYM treatmentprogrammeResults for the 26 children who provided pre- and post-treatment data showed a markedimprovement in ADHD symptoms as measured on the Conners Parent–Teacher Ques-tionnaire over the course of the meditation programme. Mean scores decreased fromMpre = 22.54, SD = 4.61, to Mpost = 14.62, SD = 5.15. The average mean decrease inreported ADHD symptoms was 7.91 points (SD = 4.91, range 0–19), which representedan improvement rate of 35%. Statistical analysis using paired samples t-test showed thatthe difference in pre- and post-treatment scores was highly significant (t = 8.23, p < .001).

Because of the possibility that the improvement in behaviour may have been due tothe medication children were receiving rather than the SYM programme, furthercomparisons were made to assess whether medication status may have contributed tothis change. Results presented in Table 1 (lines 1 and 2) show a similar reduction inADHD symptoms for the 20 children who were receiving medication compared with the6 who were not, mean reduction scores = 7.83 (SD = 5.15) and 7.95 (SD = 4.97), respec-tively (t = –.50, ns). This result suggests that the reduction in ADHD symptoms was notrelated to children’s pharmacological treatment.

It was also noteworthy that, in a number of cases, parents stated that they had beenable to reduce their child’s medication during the course of the SYM programme. Of the20 children who were receiving medication when they started the programme, 11 hadreduced the dose during SYM treatment – two by less than half, six by half, and three bymore than half – and nine did not change the dose. Table 1 (lines 3 and 4) presents thechange in ADHD symptoms data for these two subgroups. Comparison of means indi-cated that the improvement in the level of ADHD symptoms was significantly greater forthe 11 children who had reduced their medication (Mreduction = 10.18, SD = 4.79) than forthe 9 who had maintained the same level of medication (Mreduction = 5.22, SD = 3.83;t = 2.51, p = .022). These findings suggest that SYM treatment not only contributed to thereduction in children’s ADHD behaviour scores, but also had the added benefit of helpingchildren manage their own behaviour with a reduced level of medication.

Post-treatment interviews with the children showed that being able to stop or reducedaily medication was seen as a positive outcome of the SYM programme. A child who


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had stopped his medication completely said he ‘felt great’, adding ‘I used to hate havingto be on my medication’. The children identified a number of other benefits of SYM, notonly during meditation itself, which was described as ‘easy’, ‘relaxing’ and like being ‘inyour own bubble, where no-one else can stop you from doing what you’re doing at thetime’, but also in other situations at home or at school. One child said meditation ‘helpsme with my headaches’; another said he was ‘getting into less of a panic’; another thatmeditation ‘gave him more energy, but not energy to get “hyped-up” ’. Many childrensaid they were able to get to sleep more easily. Benefits for attention at school were alsogiven; for example, children commented that ‘it keeps me focused on my work’; ‘it’smade me smarter’; ‘I seem to be able to concentrate more’; ‘if my friends are talkingaround me, now I can bring my mind straight back to my work’. Children also mentionedhaving fewer social problems, such as ‘not getting into trouble’ or being able to ask theteacher for help instead of retaliating when children were teasing them.

Parent perceptions of the outcomes of SYM for their child confirmed these findings.When asked if they felt their child had benefited from the SYM programme, 92% agreedthat they had. Particular benefits for the child that were rated highly (> 3 on a 5-pointscale) by parents were ‘more confident in him/herself’ (M = 3.35, SD = .93), ‘improvedsleep patterns’ (M = 3.27, SD = 1.42) and ‘more cooperative’ (M = 3.18, SD = 1.01). Highratings for benefits related to school included ‘less difficulty with the teacher’ (M = 3.64,SD = .92), ‘more able to manage schoolwork’ (M = 3.56, SD = 1.03), ‘more able tomanage homework’ (M = 3.47, SD = 1.33), and ‘positive about going to school’ (M = 3.43,SD = 1.09).

As a further test of the effectiveness of the SYM treatment in reducing ADHDsymptoms, child and family factors were tested as covariates in six repeated measuresanalyses. Child factors were sex, age and medication status (receiving medication vs nomedication); family factors were mother’s age, mother’s education (secondary vs tertiaryeducation) and marital status (single parent vs couple families). Results showed thatnone of the child or family factors contributed significantly to the model. Although these


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Table 1. Children’s ADHD symptoms during the meditation programme by medication status

Commencement Final Point Symptom Change (Week 1) (Week 6) (Week 1 to 6)————————— ————————— ————————–n Mpre SD n Mpost SD n Mreduction SD

Medication Status1

No medication 6 22.33 5.57 6 14.50 1.52 6 7.83 5.15Receiving medication 20 22.60 4.45 20 14.65 5.86 20 7.95 4.97t-value2 (p) –.12 (ns) –.06 (ns) –.50 (ns)

Reduced dosage3 11 24.00 4.90 11 13.81 7.11 11 10.18 4.79No change of dose 9 20.89 3.33 9 15.67 4.03 9 5.22 3.83t-value4 (p) 1.62 (ns) –.69 (ns) 2.51 (.02)

Note. ADHD symptoms were measured using the Conners Parent–Teacher Questionnaire.1 Medication status as reported by parents at week 1 of the treatment programme.2 t-Test analysis compared mean scores for the 20 children receiving medication with those for the 6

children not receiving medication.3 Of the 20 children who were receiving medication at week 1, 11 reduced the dose over the 6-week

programme and 9 did not change the dose.4 t-Test analysis compared mean scores for the 11 children who reduced dosage with those for the 9

children who had no change of dosage.

analyses were limited by the small sample size, they support the conclusion that thereduction in children’s ADHD behaviour scores was attributable to the SYM treatment,and not to medication status, child or family characteristics.

Changes in ADHD-associated symptoms: Pre- and post-SYM treatmentprogrammeResults presented in this section are based on group 1 children only. Standardized scoreson the PPVT indicated that there was wide variation in children’s cognitive ability(range: 48–139, M = 94.79, SD = 23.43). Eight children had moderately low to extremelylow scores (< 85), seven were average (85–115) and four had moderately high toextremely high scores (> 115). Parent ratings of behavioural indicators of child self-esteem ranged from low (2.31) to high (4.54), with the mean score for the sample(M = 3.23, SD = .75) being mid-range, according to Burnett’s (1998) descriptions.Children’s self-descriptive and self-evaluative ratings of themselves were within normalrange (M = 4.18, SD = .46, range: 3.47–4.94) in comparison with the range of scoresreported by Burnett (1996) for children of a similar age. Quality of child–parent attach-ment, as measured by Pianta’s Child–parent Relationship Scale (CPRS), ranged fromlow (2.33), which indicates insecurity in the relationship, to moderately high (4.03), whichshows secure aspects. The overall mean score for the 30-item scale was midway on a 5-point scale (M = 3.05, SD = .44) suggesting that, as a group, there were both insecureand secure qualities in children’s relationships with their parents. Examination of thesubscale scores showed that scores on the 13-item conflict subscale were elevated(M = 3.47, SD = .80), indicating that the nature of the insecurity centred on angry, diffi-cult and unpredictable interactions. This is consistent with the insecure–ambivalent orinsecure–disorganized model of attachment reported by Clarke et al. (2002) for childrenwith ADHD. Scores for open communication (3-item subscale, M = 3.60, SD = .73) andwarmth (8-item subscale, M = 4.03, SD =.48), were moderate-to-high, indicating thatdimensions of security were also evident in the child–parent relationship.

Correlation analysis showed that children who were rated by their parents as havinghigher self-esteem, and who rated themselves more highly in their self-descriptions andself-evaluations, had more secure attachment relationships with their parents,rs(19) = .47 and .47, respectively (ps < .05). ADHD symptoms were not significantlyrelated to parent–child relationship quality or child self-esteem. There was no relation-ship between PPVT scores and ratings of ADHD symptoms, child self-esteem orparent–child relationship quality.

Post-treatment scores showed that SYM was associated with significant improvementsin all of the parent-rated measures. Results are presented in Table 2. For each measure,mean pre- and post-treatment scores were compared using paired sample t-test analysis.ADHD symptom scores at the mid-point and final point were significantly lower thanthe baseline score (Mpre = 22.62, Mspost = 15.94 and 16.25, ts = 5.81 and 5.65, respectively,p < .001). A similar improvement was seen in parents’ reports of their children’s confi-dence and social behaviour, with average scores increasing by a half-point at the mid-and endpoints of the meditation programme (Mpre = 3.24, Mspost = 3.69 and 3.73,ts = –3.06 and –3.62, respectively, p < .01). Child–parent relationships also improvedduring the course of the SYM treatment, rising by one-third of a point (Mpre = 3.06,Mpost = 3.35, t = –3.34, p < .01). Examination of the subscale components of the CPRSshowed that this change was accounted for by lower scores for relationship conflict(Mpre = 3.37, Mpost = 2.94, t = 3.08, p < .01).

As a further check of the effectiveness of the SYM intervention, we tested whetherthe observed changes in ADHD symptoms, self-esteem and relationship quality from


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weeks 1 to 6 were related to individual child differences in cognitive ability, usingrepeated measures analyses with baseline PPVT scores entered as a covariate. Resultsfor ADHD and self-esteem showed no significant contribution of children’s PPVTscores, suggesting that the observed improvements were not explained by differences inchildren’s cognitive ability.

Scores for children’s self-description and self-evaluation ratings of self-esteem did notchange significantly from the commencement to the end of the meditation programme(see Table 2). It should be noted, however, that the average scores were fairly high atboth points (4.2 and 4.3 on a 5-point scale), which may partly explain the lack of signifi-cant change. Children with ADHD have been known to inflate self-reported self-esteem(Hoza, Pelham, Milich, Pillow, & McBride, 1993).

Final analyses examined the inter-relationships among the three parent-ratedmeasures by computing ‘improvement’ scores from the difference between pre- andpost-treatment scores, and comparing these using correlation analysis. Results showedno relationship between improvement in child self-esteem and changes in ADHDsymptoms or changes in CPRS scores. However, a decrease in ADHD symptoms wasstrongly correlated with an increase in CPRS scores, that is, less conflicted (more secure)parent–child interaction (r(14) = –.67, p < .01). Interestingly, the relationship betweenADHD symptoms and relationship quality at the commencement of the programme wasnot significant (r(14) = –.41, ns), but at the end of the treatment the outcome scores onthese measures were strongly correlated (r(14) = –.66, p = .01), suggesting a change infamily functioning processes during the treatment programme.

Parent responses to SYMThe SYM intervention was designed as a family treatment programme, which wasexpected to impact on parents as well as children. At the end of the programme, 92% ofparents agreed that the programme had been personally beneficial. The overall benefit


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Table 2. Changes in child outcomes and parent–child relationship quality during the meditationprogramme

Commencement Mid-Point Final Point Paired Samples t-tests(Week 1) (Week 3) (Week 6) ————————–—————— —————— —————— Time 1–3 Time 1–6

Measure M SD M SD M SD t t

1. Child OutcomesParent-ratedADHD symptoms 22.62 4.06 15.94 4.99 16.25 5.48 5.81*** 5.65***

Indicators of self-esteem 3.24 0.78 3.69 0.37 3.73 0.48 –3.06** –3.62**

Child self-reportRating of self-esteem 4.28 0.43 4.24 0.63 0.43

2. Parent–Child OutcomesChild–parent relationship 3.06 0.45 3.35 0.42 –3.34**

Conflict subscale 3.37 0.81 2.94 0.73 3.08**

Warmth subscale 3.93 0.38 4.00 0.39 –0.82Open subscale 3.55 0.71 3.71 0.70 –1.20

*** p < .001; ** p < .01.Note. ADHD symptoms were assessed using the Conners Parent–Teacher Questionnaire; parent-ratedindicators of self-esteem were assessed using Burnett’s (1998) Biobehavioural Indicators of Self-Esteem;child-rated self-esteem was assessed with Burnett’s (1994) Self-Scale; child–parent relationship wasassessed using Pianta’s Child–Parent Relationship Scale.

was rated at 4 (M = 3.91, SD = .92) on a 1 (low) to 5 (high) scale. Specific benefits ratedhighly (> 3 on a 5-point scale) were ‘more able to manage stress’ (M = 3.79, SD = .93),‘less stressed’ (M = 3.67, SD = .96), ‘happier’ (M = 3.45, SD = 1.01), ‘more able to manageanger’ (M = 3.37, SD = 1.25) and ‘less angry’ (M = 3.29, SD = 1.23). Parents were alsoasked to rate the extent to which they felt that SYM had benefited the relationship theyhad with their child. Mean scores on a 5-point scale showed a consistent pattern ofbenefit, specifically for ‘more open communication’ (M = 3.83, SD = .72), ‘less exhaust-ing’ (M = 3.50, SD = .91), ‘more able to manage conflict’ (M = 3.42, SD = .67) and ‘lessconflict’ (M = 3.33, SD = .78). A number of parents commented that participating in theprogramme had made a positive change to their relationship with their child. A fathermentioned his pleasure at being able to laugh with his son for the first time in years. Onemother wrote ‘I truly understand how me meditating and becoming more relaxed hashelped my son 150% because he feeds off a calmer mum.’ Parents also said they had usedmeditation at home to help deal with difficult situations. One mother commented ‘I’mnow able to get N. . . to calm down (using meditation). He is then able to focus and carryon with his day.’ Another wrote about how she dealt with a difficult time: ‘We had a goodmeditation and he went off to bed quite calm and relaxed and went straight to sleep.’

Discussion

The results of this trial programme indicate that Sahaja Yoga Meditation has potential asa promising therapy for children with ADHD, when offered via a family treatmentapproach and in combination with existing medical treatment. Although results arelimited by the small number of children for whom complete data were available, theconsistency of the findings, which drew on different measures of child outcomes, twotreatment groups, and both parent and child respondents makes a good case for thebenefits of the treatment programme. The results were in keeping with the three aims ofthe study. First, core symptoms of ADHD were improved: parent ratings on the ConnersParent–Teacher Questionnaire, which assesses attention, hyperactivity and impulsivity,were significantly reduced over the course of the programme. Children also reported thatthey felt calmer, less panicky and more relaxed. Second, associated symptoms of ADHD,such as anxiety and poor confidence, were reduced; parent ratings of child self-esteemshowed significant improvements in children’s confidence, social abilities and involve-ment. Third, functional benefits were noted, child–parent relationship quality improvedthrough a significant reduction in the level of conflicted interactions. Parents reported thatthe children’s approach to school and homework had improved during the SYMprogramme, and the children themselves said that they were more able to concentrate atschool. Improved sleep was another positive outcome reported by parents and children.

The study design, as a clinical treatment trial, did not include a formal control group,but the ‘waiting list’ children provided a quasi-control group that provided evidence forthe effectiveness of the SYM intervention, over other possible contributors. For thisgroup, baseline ADHD scores at recruitment and at week 1 of the treatment programme(several months later) remained the same, and then decreased significantly over the 6-week SYM programme. Statistical evidence for the benefits of SYM was also demon-strated in a series of repeated measures analyses, which entered child and family factorsas covariates. These tests showed that the reduction in ADHD symptoms and theimprovements in self-esteem and child–parent relationship quality were not explainedby child age, sex, medication status or cognitive ability, or by family structure, mothers’age or education.

This initial investigation of SYM for managing ADHD was not able to include the


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design features of a clinical trial, which would allow allocation and comparison of treat-ment groups such as SYM in combination with pharmacological treatment and SYMalone. The children who entered the programme also varied in the severity of theirADHD symptoms and use of medication. Three-quarters of the children were receivingpsycho-stimulant drugs at the commencement of the programme and combined this withthe SYM treatment, whereas the non-medicated children used only SYM. Although thenumbers in the latter group were very small, it was noteworthy that the observed reduc-tion in ADHD symptoms did not differ by children’s initial medication status. Furtherevidence that the improvements were attributable to the SYM intervention (and not tomedication) comes from the fact that over half of the children who were takingprescribed medication had been able to reduce their medication during the course of thetreatment, and these children also showed significantly greater improvements in ADHD-related behaviours than the children who maintained their initial level of medication.The fact that the SYM effects occurred regardless of concurrent medication suggests aninteresting corollary to reports from the Multimodal Treatment (MTA) study of childrenwith ADHD that ‘intensive behavioural treatments are a viable alternative to medi-cation in treatment of ADHD’ (Pelham et al., 2000, p. 523). In the current study, thetreatment was not behavioural, but it was intensive in design, involving parents andchildren in twice daily meditation sessions at home and regular clinic sessions withtrainers. Like the MTA findings, the SYM results are encouraging for parents andcommunities seeking ways to minimize child medication.

Despite these promising results, the study is not without its limitations. The smallsample size has been mentioned. Also, this study was a within-group design and we didnot include a control group. A replication including a control group and larger numbersof participants will be essential to replicate the observed findings. It is also possible thatthe findings of the study are biased by the relatively high drop-out rate (26 and 30% forgroups 1 and 2, respectively). It is conceivable that some of those parents who did notcontinue the treatment were also those who did not notice an improvement. Anothercriticism is that significant findings relied solely on parent-rated questionnaires and thatthe reported improvements in child outcomes and child–parent relationship might beascribed to parents wanting to present themselves and their child in the best light. If thiswere the case, however, one would expect to see similar levels of change across the threeparent-rated questionnaires, whereas results showed that improvement in ratings of self-esteem were independent of improvements in ADHD symptoms and relationshipquality. This suggests that parents were not reporting a non-discriminate or overlypositive picture of their child, but were giving an accurate report based on observedbehaviour. We also note that other studies have shown that parents’ ratings of theirchildren’s improvements are similar to ratings by teachers and counsellors (Pelham etal., 2000). Furthermore, endpoint interviews with the children provided many examplesof the benefits they had experienced from the SYM programme, which supports theaccuracy of their parents’ reports. Child-rated scores on our self-report measure of childself-esteem did not show any change over the 6-week intervention. We noted, however,that self-report scores had been relatively high at both points, which is in keeping withprevious research suggesting that children with ADHD may inflate self-rated measuresof self-esteem (Hoza et al., 1993). This would make it difficult to interpret child scoresreliably. It may also be that the measure used in the present study, which was notdesigned for clinical samples (Burnett, 1994, 1998), does not adequately tap the problemsof self-esteem that children with ADHD suffer. Future study designs will have to usevalid and reliable outcome measures of child functioning, and draw on a range of sourcesincluding data provided by teachers, as well as parents and the children themselves.


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Questions remain about the underlying processes that may account for the success ofthe SYM intervention. The strong association between decreased ADHD symptoms andgreater security in the child–parent relationship over the course of the SYM programmepoints to a transactional model of effects. The observed interrelationship betweenADHD symptoms and conflict in the child–parent relationship is consistent with Keownand Woodward’s (2002) finding that ‘boys who experienced less synchronous inter-actions (which are characteristic of insecure relationships) with their mothers were 8times more likely to be hyperactive than comparison children’ (p. 549). Interactionalsynchrony, they argue, is more likely when parents are more able to manage their child’sbehaviour. Because the benefits of the SYM treatment reported by parents includedbeing more able to manage stress, angry feelings, and conflict in relationships with theirchild, it is not implausible to suggest that an important outcome of the meditationprogramme was parents’ sense of being more relaxed and competent in dealing with theirchild’s ADHD-related problems. Relationship benefits may also be linked to the natureof the intervention, which provided instruction for parents in SYM techniques that theycould use with their child at home.

Although the mechanism of action of SYM in managing ADHD has yet to beidentified, a neural regulatory mechanism also seems likely. Recent modern functionalimaging studies have shown that the reduction of thoughts in the meditation processreduces activity in frontal and other cortical brain regions (thought to originate thoughtprocesses), whereas increasing activation in limbic brain areas (Lazar et al., 2000; Lou etal., 1999). High-resolution EEG studies have shown that SYM leads to increased alphaand theta power over anterio-frontal and fronto-central brain regions, and to reducedcomplexity of EEG patterns (Aftanas & Golocheikine, 2001, 2002). Because decreasedcomplexity of the EEG from fronto-cortical regions is correlated with increased atten-tional control over cognitive processing (Lutzenberger, Preissl, & Pulvermuller, 1995;Molle et al., 1995), it has been suggested that reduced complexity of EEG patterns duringmeditative experience in SYM may reflect switching off irrelevant networks for themaintenance of focused internalized attention and inhibition of inappropriate infor-mation (Aftanas & Golocheikine, 2002). It is thus possible that the causal mechanismunderlying the positive effect of SYM on the improvement of ADHD symptoms occursvia changes on frontal brain activation in ADHD children during the meditation.Because frontal dysfunction is the most consistent finding in ADHD (Rubia & Smith,2001), a change in frontal brain activation during the 6 weeks of SYM may well havebeen the cause for symptom improvement.

Other possible, yet unexplored mechanisms of action, could be a balancing effect ofmeditation on neurotransmitter systems. In fact, a recent study using positron emissiontomography has shown that meditation increases endogenous levels of dopamine in thestriatum by as much as 65%, which correlated with an increase in EEG theta activity(Kjaer et al., 2002). As ADHD has been associated with elevated dopamine transporter(DAT) levels (Cheon et al., 2003; Dougherty et al., 1999; Krause et al., 2000), a medi-tation-induced change in endogenous striatal dopamine levels could, in fact, be aplausible hypothetical mechanism for the amelioration of ADHD symptoms. Furtherresearch using modern imaging techniques will be necessary to explore the mechanismsof action of SYM.

In sum, this is the first study investigating the effect of Sahaja Yoga Meditation as treat-ment for ADHD behaviours. The study aimed to investigate SYM as an additional family-oriented treatment, alongside any conventional medical treatment that was received bythe children, and the design of the study was not meant to compete with medication treat-ment. Preliminary findings provide initial evidence of the benefits of SYM in alleviating


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the behavioural symptoms of children diagnosed with ADHD, confirmed through parentreport and children’s own evidence. According to the children, these benefits extendedbeyond the immediate environments of the home into the classroom. Future directionsin SYM research would be well served by larger studies that involve teachers as well asparents in following children’s progress, and longer term studies with follow-up assess-ments to examine the longevity of the treatment method. Furthermore, the fact thatconfirmatory analyses provided evidence that medication did not add significantly to thechanges observed with SYM, it may be of interest for the future to compare the medi-tation effects in medication-free and medicated children, or even to compare SYM withother behavioural treatments for ADHD. Rigorously controlled clinical trials on largerand more homogenous populations would be needed to provide the necessary rigour toassess the relative effect of SYM as an alternative or complementary treatment forADHD. However, the indications are that SYM may offer families an effective manage-ment tool for family-oriented treatment of childhood ADHD.

Notes

1. Of the 15 children placed on the ‘waiting list’ at recruitment, 12 returned to commence thesecond treatment programme.

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1

SAHAJA YOGA: AN ANCIENT PATH TO MODERN MENTAL HEALTH?

Author: Dr. Adam Morgan.

Position: Clinical Psychologist working in adult mental health and child

development for the Exeter and District Community Health Service

NHS Trust. This research was completed as part of a doctoral

program in Clinical Psychology at the University of Plymouth.

Mailing address: Clinical and Community Psychology Services, R.D.&E. Hospital,

Church Lane, Wonford, Exeter, EX2 5SH, Devon, England.

e-mail: [email protected]

2


Abstract

The present study looks to evaluate the effectiveness of the meditative practice

of Sahaja Yoga as a treatment for the symptoms of anxiety and depression. It compared

a ‘waiting list’ control group, a cognitive-behavioural (CBT) based stress management

group and a Sahaja Yoga meditation group.

The results show that, compared to controls, the participants in the Sahaja Yoga

group reported significant reductions on all measures of symptomology, however, the

CBT based group showed no such reductions. Limitations of the study, barriers to the

use of Sahaja Yoga in mental health services and the need for future research are

considered.

3


Introduction

The Practice of Meditation

In the broadest sense meditation is a religious discipline in which the mind is

focused upon a single point of reference (Concise Columbia Encyclopaedia, 1991), thus

it encompasses the more Christian practices of contemplation of a spiritual theme,

question or problem as well as Eastern practices of focused attention (ibid.). Wherever

meditation is practised it’s aim is to enlighten and ultimately to confer a state of

emancipation, or transcendence of suffering, upon the practitioner.

The promise of liberation from suffering, or a realm beyond and above ‘typical’

human awareness and endeavour, forms an essential and persistent theme that runs

through all religious writing. Each religious tradition has a name for such a realm,

Christian tradition calls it ‘The Kingdom of Heaven’, Buddhist and Hindu traditions

‘Nirvana’, the Sikh tradition ‘Sahaja Samahdi’.

Within the Eastern traditions in general the generic term for the path towards

freedom from suffering is yoga (Mascaro, 1965), a Sanskrit word meaning union.

Meditation is seen as an essential tool in the practice of yoga (ibid.) and hence in the

achievement of ‘Nirvana’ (see De Silva, 1990) and thus the transcendence of suffering.

Indeed some authors have argued that religious notions of transcendence, can

be considered to be ‘ideals of mental health’ (see Neki, 1975).

Trails into the efficacy of mediation upon mental health

The contemporary trials that have been published (e.g. Kabat-Zinn et. al., 1992;

Putai, 1992; Pearl and Carlozzi, 1994; Miller et. al., 1995; Astin, 1997) indicate that a

practice of meditation is effective in reducing anxiety. However of these studies only that

of Kabat-Zinn et. al., (ibid.)i uses a clinical population.

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Teasdale et. al. (1995) have presented a theoretical paper arguing that

meditation could also prove effective in the prevention of depressive relapse arguing that

meditation prevents people from floating away into the “…elaborate, ruminative thought

streams” (ibid., p.34) seen to generate depressive states.

Furthermore Emavardhana and Tori (1997) found that following seven day

Vipassana meditation retreats, compared to controls, meditators showed significant

positive gains in self-esteem.

Overall there would, therefore, appear to be a range of support for the assertion

that a practice of meditation can be an effective means of improving ‘mental health’.

Contemporary explanations of meditation

Within contemporary psychology most ‘mainstream’ attention has tried to explain

meditative practice using cognitive and/or behavioural models. For example Teasdale

et. al. (1995) and Astin (1997) suggest that mindfulness meditation influences affect via

its effect upon information processing, whilst De Silva (1984; 1990) draws parallels

between Buddhist practices and cognitive behavioural psychology, claiming that a range

of contemporary techniques have been foreshadowed by Buddhist tradition. One

common explanation of the therapeutic effect of meditation is that it is a form of

systematic desensitisation, allowing exposure to traumatic material to occur whilst in a

relaxed state (see Delmonte, 1990; Epstein, 1990).

Psychoanalytic frameworks have also been suggested (see De Silva 1990;

Delmonte, 1990; Epstein, 1990; Haartman, 1994) with these often focusing on the

concept of the ‘ego’ and its place within a healthy psyche. This would appear to be an

‘issue’ due to the striving of meditators to achieve a state of egolessness in search of the

Ultimate, a practice that appears rather unwise when considered from a psychoanalytic

viewpointii.

Sahaja Yoga

5

Sahaja Yoga is principally a method of meditation that was founded in 1970 by

Shri Mataji Nirmala Devi. In what follows I shall attempt to briefly present Sahaja Yoga

as a set of propositions.

The ‘subtle body’

The first proposition made by Sahaja Yoga is that within us there exists a ‘subtle

body’ of seven ‘Chakras’ (centres of awareness), three ‘Nadis’ (left, right and central

‘channels’), and the ‘Kundalini’ (a Divine feminine power). Descriptions of this system

can be found within a variety of traditions, see for example Arabi (1982), ‘Sabiquun’;

Bhagavad Gita, Ch. 14; Descieux (1998); Jnaneshwari, Ch.6; Surah Nuh (Noah), v15-

16: Koran; Surah Ar-Ra’d (The Thunder), v 2: The Koran; Zechariah, chapter 4, v2-3:

Old Testament; see also Rai (1993).

The objective of Sahaja Yoga meditation is to awaken the Kundalini so that

She rises up through the subtle system to bestow the state of Yoga upon the meditator.

The seven Chakras

The Chakras can be thought of as types of awareness that correspond to certain

qualities and are said to physically lie along the spinal column. Briefly, starting at the

bottom Chakra and moving upwards, the qualities are described as;

1) Innocence (freedom from corruption)

2) ‘True’ knowledge (freedom from ignorance)

3) Satisfaction (freedom from desire)

4) Security (freedom from fear)

5) ‘Collectivity’ (freedom from ‘identity’)

6) Forgiveness (freedom from anger/resentment)

7) Joy (freedom from suffering).

6

Through the awakening of Kundalini these qualities of being are said to blossom

within the individual.

Kundalini

Kundalini is described within Eastern religious, or spiritual, tradition as an

indwelling Divine feminine energy that can be awakened in order to purify the subtle

system and ultimately to bestow the state of Yoga, or Divine Union (e.g. see Rai, 1993;

Jnaneshwari Ch. VI). This awakening involves the Kundalini moving up the central

channel, piercing the Chakras along the way, to reside within the Sahasrara Chakra

above the head (see for ex. Jnaneshwari Ch. VI). This movement of Kundalini is felt by

the presence of a cool or, in the case of imbalance, a warm breeze across the palms of

the hands or the soles of the feet. Such a phenomenon can be seen to be described in

a diverse array of scripture (see Aquarian Gospel of Christ, ch. 44, v19, ch. 161, v35, ch.

162, v4; Jnaneshwari, ch.6; Ezekiel, ch. 37, vs. 5-6: Old Testament; John, ch. 14 vs. 15-

17 & 25: New Testament; Koran, sura 24, vs. 24; sura 35, vs. 9; sura 36, vs. 64; see

also Descieux, 1998iii.). It is through attention to these sensations that areas of difficulty

can be identified and ‘worked on’ in order to strengthen the meditation.

Once ‘Kundalini awakening’ has taken place and is established through

meditation the Kundalini is said to automatically purify the subtle body and thus dispel all

mental, physical and spiritual ‘dis-ease’iv.

So far a range of studies examining the physical health benefits of its practice

have returned encouraging results (Rai et al., 1988, Gupta et al., 1991; Rai, 1993;

Panjwani et. al., 1995; 1996 and Chugh, 1997), however, as yet, no studies have looked

at the effect of its practice upon mental health problems.

Summary

The present study, comprises of a clinical trial into the effectiveness of Sahaja

Yoga meditation in the alleviation of mental distress. The trial was conducted at the

7

Victory Centre, in Devon, a group work centre for adults with mental health problems.

Methods

Design

The present study uses a ‘quasi-experimental’ comparison of 3 independent

groups; a Sahaja Yoga meditation group, a CBT group and a waiting list control group.

Due to the lack of random allocation to treatment group pre-treatment measures were

used to check for initial non-equivalence between groups.

Participants

Selection and allocation

Participants were chosen from referrals to the Victory Centre and came from a

variety of sources, including GP’s, Clinical Psychologists and Psychiatrists as well as

internal referrals and reviews.

All participants were assessed to be primarily suffering from recognised

symptoms of ‘anxiety’, with or without symptoms of depression as well.

Participants were allocated to treatment group on the basis of assessed

suitability. In practice this meant that staff made efforts to refer more ‘introspective’

people into the Sahaja Yoga group and more ‘outward looking’ people into the CBT

group. This procedure was an attempt to prevent ‘clinically inappropriate’ mismatches

between participant ‘style’ and treatment type, which was a concern of assessors at the

Victory Centre.

Sample composition

24 participants completed the study, of these 24 eight were in the Sahaja Yoga

group, 10 in the control group and six in the CBT groupv. The gender distributions,

mean ages, standard deviations and ranges, in years, for each group are shown in table

8

1 below.

Ethical procedures

Local ethical committee approval for the present study was sought and, after

some changes to the treatment protocol (see below under ‘Procedure’), received.

Measures

In order to evaluate changes in ‘symptom severity’ both the Hospital Anxiety and

Depression scale (HADs; Zigmond and Snaith , 1983) and the twelve item General

Health Questionnaire (GHQ-12) (see Goldberg, 1978), were used.

The HADs produces two scores, one for depression and one for anxiety (see

Snaith and Zigmond, 1994). The GHQ-12 was chosen as a supplement to the HADs as

it is a reliable general indicator of clinically significant non-psychotic mental disorder.

Procedure

Symptom severity was measured both before the start of treatment and post

treatment, with the control group participants being posted the questionnaires at the

appropriate times. All three groups ran concurrently with data being collected within the

same 10 day period at both pre and post-treatment intervals. Each group is described

below;

a.) Anxiety management (CBT) group

The anxiety management group consisted of a six week, two hour long group

that uses a cognitive-behavioural approach to helping people cope with the symptoms of

anxiety.

b.) Sahaja Yoga meditation group

This group also consisted of a two hourly six week program and aimed to teach

Sahaja Yoga meditation. However due to the medical ethics committee’s concerns

about the possibly ‘quasi-religious’ nature of the group the meditation was taught as a

9

‘technique’ with all explicit references, and contextual material, related to religion

removed. Thus this group concentrated on teaching participants the ‘skill of meditation’

using an internal motherly energy (Kundalini) and seven inner qualities (Chakras).

c.) Control group

The control group consisted of individuals who had already been referred into a

pre-existing treatment group and were waiting for this group to begin.

Resu l ts

Pre-treatment comparisons

There were no significant differences between groups for age (one way ANOVA

F(2,21)=0.20, p=0.82), or gender (Chi-squared (Pearson)=2.47, d.f.=2, p=0.29) nor a

preponderance of one gender in the sample as a whole (Chi-squared (Pearson)=0.67,

d.f.=1, p=0.41).

Equally no significant pre-treatment differences between groups for any of the

‘symptom severity’ measures were found (one way ANOVA, HADs anxiety F(2,21)=0.40,

p=0.68; HADs depression F(2,21)=0.15, p=0.86; GHQ-12 F(2,21)= 0.85, p=0.44). The

means, standard deviations and ranges of each of these variables is shown below in

table 2.

Analysis of treatment effects

Treatment effects were analysed using both MANOVA and repeated measures

ANOVA tests. No significant violations of the statistical assumptions of these tests (see

Howell, 1997; Maxwell and Delaney, 1990; Tabachnick and Fidell, 1989) were foundvi.

A MANOVA, including all the pre- and post-treatment variables showed there to

be a non-significant main effect of ‘group’ F(6,38)=1.46, p=0.22, significant main effect of

10

‘time’ F(3,19)=19.70, p<0.0005 and significant ‘group by time’ interaction F(6,38)=3.10,

p=0.014.

Repeated measure ANOVAs (one for each individual variable) were conducted to

identify which variables were responsible for this effect.

All three ANOVAs showed the same pattern of results as the MANOVA, i.e. a

non-significant main effect of ‘group’ (HADs anxiety F(2,21)=1.37, p=0.28; HADs

depression F(2,21)=1.25, p=0.31; GHQ-12 F(2,21)=2.73, p=0.09), a significant main

effect of ‘time’ (HADs anxiety F(1,21)=28.79, p<0.0005; HADs depression F(1,21)=9.42,

p=0.06; GHQ-12 F(1,21)=43.30, p<0.005) and a significant ‘group by time’ interaction

(HADs anxiety F(2,21)=5.84, p=0.01; HADs depression F(2,21)=3.46, p=0.05; GHQ-12

F(2,21)=7.13, p=0.004).

On inspection these results show that there is a significant reduction in symptom

severity (main effect of time) and furthermore that this reduction differs significantly

between groups (significant group by time interaction effect). Independent sample t-

tests were used to further examine this effect.

All t-tests showed the same pattern of results; the Sahaja Yoga group showed a

significant improvement as compared to the control group (HADs anxiety t=3.20,

d.f.=16, p=0.006; HADs depression t=2.46, d.f.=16, p=0.026; GHQ-12 t=4.33, d.f.=16,

p=0.001), however the CBT group did not show a significantly greater improvement than

the control group (HADs anxiety t=1.44, d.f.=14, p=0.17; HADs depression t=1.15,

d.f.=14, p=0.27; GHQ-12 t=1.32, d.f.=14, p=0.21).

There was no significant difference between the two treatment groups (HADs

anxiety t=1.77, d.f.=12, p=0.10; HADs depression t=1.31, d.f.=12, p=0.21; GHQ-12

t=1.85, d.f.=12, p=0.089), although the HADs anxiety and GHQ-12 results are indicative

of a trend in the data (p=0.10 and p=0.089 respectively).

11

Discuss ion

The above results lend support to the hypothesis that participants in the Sahaja

Yoga meditation group would show a significant reduction on measures of symptom

severity, over and above that which could be expected due to spontaneous remission.

Surprisingly, they do not lend support to the hypothesis that participants in the CBT

based stress management group would show a similar reduction, however the CBT

group was by far the smallest and thus suffers from significantly reduced statistical

power.

Interpreting the results

Like most therapy outcome studies the present one falls short of experimental

ideals in many ways, however despite this it would seem reasonable to conclude that

there is at least encouraging evidence in support of the statement that participation in

the Sahaja Yoga meditation group did result in significant reductions in levels of reported

symptomology over and above that which could be expected from spontaneous

remission.

The present study is, however, not able to shed light upon therapeutic process.

It is still the case that identifying the precise mechanisms responsible for outcome, in

psychotherapy process research, remains an elusive and frustrating task (see Erwin,

1994). As many others have said before, attempting to assess such factors remains an

important task for future research.

The present research in context

The available research literature into the therapeutic efficacy of Sahaja Yoga is

very small indeed (see Rai et al., 1988, Gupta et al., 1991; Rai, 1993; Panjwani et. al.,

1995; 1996 and Chugh, 1997) with this being the first study to be conducted into its

efficacy as a treatment for mental health problems. Thus it forms an important addition

12

to this small literature and adds cautiously to the evidence already available in support of

the hypothesis that Sahaja Yoga is generally ‘therapeutic’. Compared to those studies

already published the present research is of similar sizevii and methodologyviii.

Outside of this literature, as described earlier, there are an equally small number

of published contemporary studies (see for example Kabat-Zinn et. al., 1992; Pearl and

Carlozzi, 1994; Miller et. al., 1995; Astin, 1997) that show the practice of meditation,

usually ‘mindfulness’ meditation, to be of significant therapeutic value in the treatment of

anxiety. Of these studies, however, only Kabat-Zinn et. al., (1992) uses a clinical

population. The present study is, therefore, something of a rarity in its use of a clinical

population and also derives a certain value here as a result.

Sahaja Yoga in ‘clinical’ practice?

I believe that the practice of Sahaja Yoga could be valuable in services that aim

to alleviate mental distress. For example Teasdale et. al., (1995) argue that meditation

has many advantages over cognitive therapy, especially in relation to relapse prevention

because it can be practised in the absence of distress and in any situation. In support of

this suggestion Miller et. al., (1995) present three year follow-up data on participants

from the Kabat-Zinn (1992) study and show a maintenance of gains in all 18 subjects

who were contactedix.

One difficulty for Sahaja Yoga is that it would be necessary Sahaja Yoga

‘teachers’ to be practitioners themselves (see Prakash, 1997). Perhaps a more

problematic barrier, however is the nature of its ‘theory’. In ‘Western’ healthcare

services the ideas that Sahaja Yoga presents are unconventional and controversial, and

it is no surprise that all the published studies that are available are to be found in Indian

journals.

Indeed the present research encountered considerable resistance during its

implementation related largely to the nature of the ‘theory’ of Sahaja Yoga. Having said

13

this, a set of proposals were eventually agreed upon which maintained, to some degree,

the essential aspects of the practice. I am also aware of an, as yet unpublished, study

into Sahaja Yoga that has been conducted within the University of New South Wales

Faculty of Medicine in Australia, further suggesting that Western Institutions can be open

to its use.

Future research

Apart from replicating the present study and addressing its shortfalls it would be

interesting to try and evaluate individual elements of the practice of Sahaja Yoga,

however it would be extremely difficult to experimentally verify hypothesised events such

as Kundalini awakening. One way forward might be to use a mixture of qualitative and

quantitative methods. For example subjective accounts of the sensations that people

experienced during meditation could be collected from two groups, a Sahaja Yoga

meditation group and a relaxation ‘control’ group. Whilst this would clearly not

experimentally ‘prove’ Kundalini awakening, it would at least be interesting if it turned out

that only the Sahaja Yoga group felt a ‘cool breeze’, or other similar sensations during

meditation. Another option could be to compare the subjective accounts of meditating

upon this cool breeze (i.e. concentrating on it) as compared to meditating upon ones

heart beat, or breath. Such studies, designed to look at the experience of ‘Kundalini

awakening’, would not necessarily need to use clinical populations, which may ease

their implementation.

Conclusion

In conclusion the present study adds to the existing literature suggesting that

Sahaja Yoga in particular, and meditation in general, has therapeutic value. Whilst it

would seem that Sahaja Yoga could form a valuable part of service provision there are

problems to be overcome before this becomes a reality.

14

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17

Sahaja Yoga CBT Control

Mean Age

(years)

37.13 39.17 37.00

Standard

deviation

8.48 2.56 7.60

Range 27-49 36-43 27-53

Female (n) 6 2 6

Male (n) 2 4 4

Table 1. Means, standard deviations, range of ages and gender N’s, by group.

18

Sahaja Yoga CBT Control

HADs anxiety

mean score 12.25 14.17 13.80

standard deviation 4.06 4.88 4.44

range 7 - 20 7 - 19 5 - 19

HADs depression

mean score 7.25 8.17 8.10


range 0 - 11 2 - 15 1 - 14

GHQ-12

mean score 18.75 24.33 19.70


range 10 - 32 11 - 35 5 - 35

19

Table 2. Means, standard deviations and ranges of pre-treatment scores, by group.

Acknowledgements

I would like to thank all the staff from the Clinical Teaching Unit at the University

of Plymouth, particularly Dr. Tony Carr and Dr. Reg Morris, for supporting this research

through some fairly difficult times.

Secondly I would like to thank all the staff at the Victory Centre, in Exeter, for all

the effort that they put into actually making it happen.

Thirdly I would like to thank Russell and Leela Howard, and Clive Reid for all

their input into running the Sahaja Yoga meditation group, and for making it such an

enjoyable experience.

Finally I would offer my thanks to Shri Mataji Nirmala Devi for her continued effort

in teaching Sahaja Yoga to those who are interested, without this effort Sahaja Yoga

wouldn’t be available to study.

20

i The study by Miller et. al., (1995) reports follow up data from Kabat-Zinn et. al., (ibid.) and is thus not a different study. ii Psychosis is often seen by psychoanalytically orientated theory to be the end result of removing ‘ego boundaries’ (see Epstein (1990) and Hartman (1994) for a discussion of these issues). iii Many more references exist, too many to list exhaustively here. iv A more detailed description of the method and theory of Sahaja Yoga is available from the author at the address given earlier. v The CBT group is, therefore, statistically too small and thus has insufficient statistical power. vi The only exception here was the presence of an outlier. As recommended by Tabachnick and Fidell (1989) this case was changed and assigned a score “… one unit larger (or smaller) than the next most extreme score in the distribution.” (ibid., p. 70). However this change had no significant effect on any of the results and thus the data point is left unchanged as an outlier in this analysis. vii N’s for the other studies are Rai et. al., (1988), N=20; Chugh (1997), N=25; Gupta et. al., (1991), N=18; Panjwani et. al., (1995), N=18; Panjwani et. al., (1996), N=10. viii All the published studies report comparisons to control subjects, however the papers that I have direct access to do not detail whether or not randomisation was used. ix In the original study there were 22 participants, of which 20 showed a maintenance of gains at three month follow-up. Of the four people for whom data are not available, one declined to participate, one was unreachable and two were ‘non-compliant’ with attempts to schedule interviews.

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Can meditation reduce work stress?By Dr Ramesh Manocha of Sydney’s Royal Hospital for Women

Scientific studies have consistently found that meditation does not give better results than taking a short nap, listening topleasant music or thinking pleasant thoughts. However, according to recent research, the application of a new definition ofmeditation involving "mental silence" appears to have effects substantially greater than this, especially with regard to the impactof stress.

Although more than 3,000 scientific studies exist on meditation within the major scientific databases, only about 4% are reportson randomised controlled trials (RCTs) the only way to reliably exclude the placebo effect. Researchers who havesystematically evaluated these RCTs consistently find that meditation, as it is practised and defined in western society (egrelaxation, attention focusing and mindfulness), is little more than a sophisticated way of generating a placebo effect.Descriptions of the meditative experience that originated in ancient India, however, reveal that a key feature of meditation is theexperience of mental silence. Western definitions have not emphasised this feature.

Currently, the Royal Hospital for Women’s Meditation Research Program (MRP) is systematically evaluating the mental silenceperspective of meditation. Over the past nine years, a multifaceted evaluation program has been conducted to evaluate the effectof mental silence on a variety of health and behavioural factors, especially stress.

Key studies

In 2000, a health and wellbeing survey of 348 long−term meditators who used a single, homogenous form of meditation calledSahaja Yoga (SYM), which focuses on the experience of mental silence, demonstrated that these meditators had better mentaland physical health than the general population. It also showed that a consistent relationship existed between health, especiallymental health, and how often meditators reported experiencing mental silence.

An RCT of SYM for asthma demonstrated that mental silence meditation not only was significantly more effective at improvingpsychological factors and quality of life when compared to a standardised stress management strategy, but also showed that itreduced the severity of the physical disease process, whereas stress management did not (Manocha R et al, Thorax 2002; 57:110−115).

Having recognised that the most profound effects of mental silence appeared to be related to mood, anxiety and stress, thepotential of this approach for the management of occupational stress was obvious. Thus, in 2001 the MRP designed andimplemented the Meditation for Work Stress project, the largest RCT of meditation for occupational stress currently in theliterature (178 participants). The study was specifically designed to determine whether or not this approach to meditationresulted in more than just a placebo effect.

The stress management program was eight weeks in duration and involved one−hour evening sessions twice weekly, delivered atSydney Hospital. Participants travelled directly from work to the sessions. They were asked to practise mental silence meditationtwice daily for approximately 10−15 minutes each time with the aid of written and audio materials. Between classes, instructorsmade themselves available to take queries or give specific advice to participants.

A comparison group was selected that was also meditating but focused on the conventional western idea of meditation(relaxation and contemplation, rather than mental silence). A second comparison group comprised a no−treatment waiting list.

Classes for both intervention groups were conducted at the same locations, in similar rooms, at the same time of day, and wereof equal duration. Both groups had experienced health professionals as principal instructors. Thus, the two interventions werestructured identically, with the core experience of mental silence being the only major difference.

At the end of the eight−week program, the SYM group demonstrated significantly greater improvements in standardisedmeasures of work−related stress, anxiety and depressive feelings, as measured using standardised assessment tools taken fromthe Occupational Stress Inventory (OSI), the State Trait Anxiety Inventory (STAI), the General Health Questionnaire (GHQ28)and the Profile of Mood States (POMS).

The reduction in work−related stress in the SYM group was 27%, compared to 15% in the non−mental silence group and 7% inthe untreated group. Anxiety improved by 24% in the SYM and 12% in the non−mental silence group but worsened by 5% in theuntreated group. Depressive symptoms improved by 66%, 39% and 10% respectively. Standard statistical analyses demonstratedthat these changes were significant, thus confirming that mental silence has an effect greater than a placebo and probably greaterthan conventional, non−mental silence approaches to meditation.

It has been generally assumed that meditative interventions reduce stress by mitigating its physiological effects, that is, byreducing levels of stress hormones, blood pressure, etc. However, our study indicates that mental silence may do more than this.While both active interventions reduced somatic arousal, the SYM group also appeared to alter participants’ cognitions andperceptions, suggesting that changes in the way they thought and felt contributed to their reduction in stress.

For example, further analyses demonstrated that the participants in the SYM group improved their personal coping resources

OHS Alert Newsletter> 2009 > Issue 1, 13 February 2009 > FEATURE > Can meditation reduce work stress? 1

Copyright 2009, CCH Australia Ltd

(such as their ability for self care and coping skills). Similarly, participants in the SYM group also reduced their trait anxietylevels. Participants in the other groups, however, did not demonstrate these changes. Since the major differentiating feature ofSYM is mental silence, it is reasonable to conclude that this experience might somehow modify the way that we think and feelabout the various factors in our environment that contribute to stress. Thus this approach to meditation, and the state ofconsciousness called mental silence, not only mitigates the physiological impact of stress but also alters cognitive behaviouralstyle (ie the "way people think") and hence the propensity to be stressed. (This will be the major focus area for future research.)

Based on the research outcomes, a flexible, evidence−based meditation strategy for work stress has been developed andimplemented in a variety of settings, including corporate offices, healthcare institutions and government departments. Clientsinclude Caltex, IBM, law firms and a number of public hospitals. Two case studies are provided below.

Case study 1: top tier law firm

Stage 1 was a one−hour combined lecture (45 minutes) and hands−on meditation workshop (15 minutes). The aim of Stage 1was to familiarise participants with the rationale and benefits of meditation, followed by actual instruction in a basic meditationtechnique that participants could then use at home or in the workplace in conjunction with a resource kit (CD, instruction card,etc) given to each participant at the end of the session. Designed to occupy a single lunch hour, the event was advertisedinternally by HR and attracted 250 legal and administrative staff across three offices (Sydney, Melbourne and Brisbane).

Stage 2 was a three−week follow−up program providing 30−minute in−house lunchtime meditation sessions twice per week ateach office, facilitated by experienced instructors. Stage 2 aimed to teach workers more advanced meditation skills. One hundredand twenty staff participated, most attending once per week for the full three weeks. Attendance was voluntary, withapproximately 25% attrition by the end of the program. Outcomes were quantified at each stage.

Assessment of the impact of Stage 1 using visual analogue scales indicated that 73% of participants experienced a significantdegree (ie greater than 25%) of "mental silence", 80% of participants experienced a significant improvement in "calm andpeacefulness", and 62% of participants experienced a significant improvement in "stress, anxiety and tension". There was astrong correlation between participants’ ratings of the "mental silence experience" and their "sense of reduced stress" andincreased sense of "calm and peacefulness".

Participants who completed Stage 2 demonstrated improvements in resilience and stress of between 55% and 65% (p < 0.05).This was assessed using the Positive and Negative Affect Schedule (PANAS), a standardised measure designed to assesspositive feelings (associated with better attitude to work) and negative feelings (associated with stress and burnout). Qualitativefeedback indicated that participants found the initiative both enjoyable and beneficial. The law firm has requested similarprograms in its remaining Australian offices.

Case study 2: general practitioners

Health professionals, especially GPs, are among the most highly stressed professional groups, and yet stress and itsconsequences can lead to reduced ability to make important, sometimes life−saving, decisions.

Stage 1 was an afternoon workshop involving lectures on stress, work−life balance and meditation. The lectures were followedby three meditation sessions designed to teach participants basic, intermediate and advanced skills. Recognising that many GPsare too time poor and/or isolated to access ongoing support and advice in their workplace, Stage 1 aimed to impart sufficientskills, experience and familiarity to allow GPs to practise meditation at home in a relatively self−sufficient manner. Threehundred and twenty GPs participated in Stage 1, in two events (Sydney and Melbourne).

Stage 2 was a self−directed two−week home practice program. Participants were required to document their twice−daily practiceas well as their meditative experience and psychological state.

The program was endorsed by the Royal Australian College of General Practitioners so that participants could earn professionaldevelopment points essential for their medical registration. Completion of Stage 1 earned 10 points and completion of Stage 2earned an additional 40 points.

Outcomes were quantified at each stage. The Stage 1 event, as with Case study 1, was assessed using visual analogue scales.Within these, 93% of subjects experienced a reduction in their "usual mental activity", in line with the aims of the meditationtechnique. Specifically, 40% experienced a greater than 50% reduction of mental activity and 18.3% experienced a greater than70% reduction in mental activity; 96% of subjects experienced an increase in their sense of "calm and peacefulness", and 53%experienced a greater than 50% increase in "calm and peacefulness". Further, 93% of subjects experienced a reduction in theirsense of "tension and anxiety", and 46% experienced a greater than 50% reduction in "tension and anxiety". Again, theimprovement correlated with the experience of mental silence.

The Stage 2 component used the Kessler 10 (K10), a well−known psychological distress measure. One hundred and elevenparticipants who attended the event completed the home−based meditation tasks and provided pre− and post−K10 data.

At the beginning of the skilling program, 54% of the GPs were in the elevated risk category. The Australian population bycomparison has only 36% in this category. At the end of the two−week home−based program, however, 28.6% of the sample



was in the elevated risk category, that is, one quarter of the participants had improved sufficiently to shift into the low riskcategory (p < 0.001).

Qualitative feedback was very positive, with 98.8% of respondents indicating that their learning needs had been fully (53.5%) orpartly (45.3%) met, and 97.5% felt that the event was fully (56.0%) or partly (41.5%) relevant to their professional life. Thesepilot study outcomes have led us to begin designing an official program to be rolled out in the capital cities across Australiaduring the latter half of 2009.

For more information on the Royal Hospital for Women’s Meditation Research Program, email Dr Ramesh Manocha [email protected].



CLINICAL EVALUATION OF COMOBID DISORDERS

Alexander Kim

Objectives: To study the influence of the phenomenological

approach in classifications DSM-III, DSM-IV and ICD-10 on

diagnostics of the phenomenon of comorbidity.

Methods: The sample consisted of 75 patients from 19 to 65 years of

age, who were surveyed at outpatient clinics in Bishkek. Standar-

dizing scale of depression, standardizing scale of anxiety scale, and

the Sheehan Quality of Life Questionnaire.

Results: According to the results, a prevalence of complaints of

palpitation (16,8%), headaches (16.8%), breathing complications

(10.8%), pain and discomfort in chest (10.8%), and weakness and

fatigue (8.4%) were reported. The prevalence of a somatic

pathology in these systems obviously reflects the psychosomatic

nature of comorbidity, and allows one to draw analogies to the

diagnostic instructions of heading F-4, ICD-10.

According to the received results, the majority of patients

(66.15%) testified that their anxiety level was raised, both

reactive, and personal. the severity of level of depression for

the majority of patients corresponded to the norm (61.5%). For

patients with accompanying mental disorders, the parameters of

quality of life was considerably low (p B0.05) in sections both

psychological and physical. The parameters demonstrate a pre-

sence of co morbidities, in which the patient’s ‘‘somatisation’’ is

an appeal for help.

Conclusion: ‘‘Somatisation’’ is an appeal for help. The presence of

disturbing affect, allows to assume about functioning the clinical-

psychological mechanisms promoting formation secondary soma-

tisations. In structure of comorbidity somatic disorders, secondary

somatisations is realized more often, in variants presented

somatisations and pseudo-somatisations. The intensity and dura-

tion of a disturbing component in the structure of comorbidity

somatic infringements represents the mechanism of active physio-

logical reactions causing stabilization of a phenomenon of

somatisations for patients with somatic disorders. Secondary

somatisation is the clinical-psychological mechanism causing

formation of clinical typology shown somatisations and pseudo-

somatisations, which have adaptable characteristics and conduct

to leveling hipotimics affect, in the structure of comorbidity

somatic disorders.

SHORT AND LONG TERM EFFECTS OFMEDITATION ON MENTAL HEALTH OF FULLTIME WORKERS SEEKING HELP FOR WORKSTRESS

Ramesh Manocha

This presentation is the synthesis of two important studies assessing

the acute and long term effects of meditation on stress and mental

health:

First, a survey of 350 long-term meditators (greater than 2

years regular meditation using the Sahaja Yoga meditation

technique) from around Australia was conducted assessing mental

health and quality of life using the Kessler 10 (K10). The K10

data indicated that the meditating sample had a significantly lar-

ger proportion of subjects who were at low risk of mental health

problems compared to the background population. Importantly,

a highly significant correlation was found between frequency of

reported ‘‘meditative experience’’ and mental health scores in the

K10 (r�0.37, pB.001) even after controlling for standard

confounders.

Second, a double-blind randomized controlled trial of meditation

as management strategy for work stress compared to both

relaxation and a waiting list control was conducted. 178 full time

workers were recruited. They completed the GHQ 28 at baseline

and postintervention. There was a statistically significant improve-

ments for the meditation group compared to both the active control

and control group in the median differences for the GHQ score

(pB.05). The results suggest that the meditation technique is a

specifically effective strategy for reducing stress and improving

mental health.

Taken together, these two studies demonstrate that meditation

is effective in reducing stress and improving mental and

physical health. Moreover, the benefits of long term practice of

meditation are associated with frequency of practice and depth of

experience.

OP65 EARLY PSYCHOSIS

FIRST EPISODE PSYCHOSIS: MEDICATIONS ANDCLINICAL PRESENTATION IN AL AIN, UNITED ARABEMIRATES

Hamdy Moselhy Fouad, Mohammed Omar Salem, SaeedYousef

Objective: The primary aim of this work was to examine the socio-

demographic, clinical correlates, the effect of medical treatment on

the first episode psychosis in an Arabic country.

Method: A retrospective case note review, looking at first episode

psychosis who were admitted to the in-patient psychiatric ward in

Al Ain general hospital over 5 years.

Results: 161 patients with first episode psychosis were reviewed. In

the 5-year period under the study, 161 aged 13�45 years withhistory of first episode psychosis were admitted to the psychiatric

ward. They established a different clinical diagnoses according to

ICD 10: 69 patients (42.9%) had a diagnosis of acute psychotic

episode, 35 patients (21.7%) had a diagnosis of manic episode, 31

patients (19.3%) had a diagnosis of schizophrenia, 16 (9.9%) had

depression with psychotic symptoms, 3 (1.9%) drug dependence, 1

(0.6%) persistent delusional disorder, and in 6 (3.7%) patients the

data were missing.

The mean age was 27.5 years (13�45 years) (SD�6.6), male/female ratio (110/49, 68.3%/30.4%). There was a significant

relationship between duration of untreated psychosis (DUP) and

outcome, where the longer the DUP the more existence of residual

symptoms on discharge (x2�18.515, df�6, p�.005). In additionthere was a significant relationship between social withdrawal

symptom prior to admission and residual symptoms on discharge.

In addition, there was a positive significant relationship with the

use of the combination of antipsychotics and mood stablizer in

outcome.

Conclusion: Results of this study indicate that DUP, clinical

features and type of medications may determine the outcome of

first episode psychosis.

A338 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PSYCHIATRY (2007) 41 (Suppl. 2)

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Original Research Paper

Changing Definitions of Meditation- Is there a Physiological Corollary? Skin temperature changes of a mental silence orientated form

of meditation compared to rest

Ramesh MANOCHA1, Deborah BLACK2, David SPIRO3, Jake RYAN4 and Con STOUGH4

1 Barbara Gross Research Unit, Royal Hospital for Women (Randwick, Australia) 2Faculty of Health Sciences The University of Sydney, (Sydney, Australia)

3 Institute of Psychiatry, King’s College London (London, UK) 4 Centre for Neuropsychology, Swinburne University (Melbourne, Australia)

(Received on November 10, 2009; Accepted on January 10, 2010)

Abstract: [Objectives] Until very recently, the U.S. National Center for Complementary and Alternative Medicine (NCCAM) defined meditation as “a conscious mental process that induces a set of integrated physiological changes termed the relaxation response”. Recently the NCCAM appears to have reviewed its understanding of meditation, by including a new central feature: “In meditation, a person learns to focus his attention and suspend the stream of thoughts that normally occupy the mind”, indicating a shift from a physiological (“relaxation-response”) to an experiential (suspension of thinking activity) definition, more in line with traditional eastern understandings. We explore the physiological implications of this paradigmatic shift. [Design] A controlled, observational study.of acute physiological changes. N=26. Participants were asked to either meditate or rest for 10 minutes. [Settings/Location] A temperature controlled room at Swinburne University’s Psychophysiology Laboratory, Melbourne. [Subjects] 16 meditators proficient at a mental silence orientated form of meditation (Sahaja yoga, SYM) and 10 non-meditators with an interest in meditation. [Interventions] A mental silence orientated form of meditation (Sahaja yoga, SYM) was compared to rest. [Outcome Measures] Palmar skin temperature and heart rate. [Results] Throughout the meditation period mean ST of the SYM group decreased while that of the Rest group increased. After ten minutes of meditation, 13 of the 16 meditators manifested a reduction in ST compared to baseline whereas 7 of the 10 participants in the control group manifested an increase compared to baseline. Chi-Square tests showed that the difference between the two groups was significant (p=.003). Heart rate changes however did not differ between the two groups. [Conclusions] The study suggests that the experience of mental silence and rest are not psychophysiologically identical despite the fact that they are overtly similar. Implications of this, and need for further evaluation, are discussed. Keywords: meditation, relaxation, arousal, skin temperature, controlled trial, mental silence, sahaja yoga, definition

1. Introduction Until very recently, the U.S. National Center for Complementary and Alternative Medicine (NCCAM) defined meditation as “a conscious mental process that induces a set of integrated physiological changes termed the relaxation response”1. Remarkably, in 2006 the NCCAM posted a reviewed understanding of meditation on its official website, describing a new

central feature: “In meditation, a person learns to focus his attention and suspend the stream of thoughts that normally occupy the mind. This practice is believed to result in a state of greater physical relaxation, mental calmness, and psychological balance. Practicing meditation can change how a person relates to the flow of emotions and thoughts in the mind.”2. The NCCAMs shift from and emphasis on the physiology of rest to the experience of “suspension of thought activity” raises an important question about whether or not this shift in conceptualization also implies a different physiological and clinical paradigm.

_______________________________________________________ Ramesh Manocha c/o Barbara Gross Research Unit, Royal Hospital for Women Locked Bag 2000, Randwick 2031, NSW Australia Ph: 61 418 270 786, email: [email protected]

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Interestingly, the critical importance of the “suspension of thought activity” in meditation has been described in a number of traditional eastern treatises. Mascaro, an eminent translator of Eastern spiritual texts, summarises its metaphysical importance: “In the infinite struggle of man to know this world and the universe around him, and also to know the mind that allows him to think, he comes before the simple fact that life is above thought: when he sees a fruit he can think about the fruit but in the end he must eat it if he wants to know its taste: the pleasure and nourishment he may get from eating the fruit is not an act of thought” 3. For example, the Upanishads are a collection of ancient spiritual writings from India which are among the first texts to deal with the subject of meditation. In the Kaushitaki Upanishad it is stated “It is not thought which we should know: We should know the thinker”4. In the Katha Upanishad “When the five senses and the mind are still, and reason itself rests in silence, then begins the path supreme.” 5. In Patanjali’s Yoga Aphorisms, one of the first instructional treatises on yoga and meditation, it is stated “By being aware of the silent void moments pervading the emptiness between thoughts, one can glimpse and expand the skill of thought subjugation which leads to transformation..” 6. Gynaeshawara, a 12th Century Indian mystic, describes the experience as part of yogic awakening “the imagination subsides, activity becomes calm, and the functions of the body and mind stand still” 7. Non-thought consciousness is not unique to India; the ancient Japanese Rinzai Zen tradition also encompasses the principle, elegantly described in the Koan “What is the sound of one hand clapping?” 8 .The answer is, of course, that there is no sound and similarly the state of meditation involves no thinking activity. The aim of such a riddle is to challenge the mind into realizing the futility of rational thought, thus triggering a shift of consciousness toward the state of mental silence, described in the Zen tradition as “Satori” 9. As the NCCAM’s pre-2006 definition of meditation indicates, the scientific establishment has until recently come to define meditation in terms of the physiological changes that characterize the relaxation response: reductions in heart rate, blood pressure and respiratory rate and increases in skin temperature, skin resistance and alpha wave activity in the brain. So logically it should not be surprising that well-designed trials comparing the therapeutic effects of meditation-orientated practices to relaxation-orientated practices typically fail to demonstrate notable differences10.

While the extant literature in the west makes it clear that the physiological changes induced by meditation are not significantly different to those of rest/relaxation we find a report on meditation by Rai, in India which offers contradictory evidence. It describes a series of small exploratory trials of meditation in which heart rate (HR), blood pressure (BP), and respiratory rate (RR) changed in the expected directions associated with reduced arousal but digital skin temperature consistently dropped by almost 2 ºC during a single meditation session. This did not occur in the comparison group, and seemed to become more prominent as meditators became more proficient 11 . The technique evaluated by Rai, called sShaja Yoga meditation (SYM), holds as its central defining feature the experience of “suspension of thought activity” or “mental silence” (Sanskrit: “nirvichara Samadhi” which when translated literally can mean “thoughtless awareness”) ie the elimination of unnecessary thought activity while focusing the attention effortlessly on the “present moment” experience. By way of contrast with Rai’s report, our search of the English-speaking scientific literature yielded eight controlled trials assessing the physiology of meditation and its effect on skin temperature (ST) none of which report reductions in that variable: A group of novice TM practitioners showed increases in ST while paradoxically more experienced TM practitioners showed no such change when compared to a group trained in relaxation 12 ; “biofeedback-supported respiratory meditation” led to an increase in digital ST 13 ; a significantly larger increase in digital ST occurred during “mantra meditation” than a resting control 14 ; when progressive relaxation was compared to a Christianity-based “devotional meditation” within-group increases were reported but no significant difference between the two groups is described15. Four other studies reported no significant changes in skin temperature: Ananda Marg 16 ; a modified Transcendental Meditation (TM) technique 17 ; the Relaxation Response 18 ; Clinically Standardised Meditation and biofeedback 19 . Importantly, there are no reports in the western literature describing reductions in ST as a result of meditation. It should also be noted that we were unable to find any controlled studies that have assessed the effects of either mindfulness or mental silence styles of meditation on ST. Recently, Manocha et al. (2002) conducted a randomized, controlled trial that was specifically

25

directed at detecting the therapeutic differences between “mental silence” orientated meditation versus relaxation. Here, SYM was used as a “mental silence” orientated intervention and compared to a standard stress management program matched for expectancy and other nonspecific effects in 59 people with moderate to severe asthma. At post-intervention the meditation group demonstrated significant improvements in mood state, aspects of asthma-specific quality of life, and, importantly, airway hyper-responsiveness (AHR), a relatively objective measure of patho-physiological severity. The change in AHR was both clinically and statistically greater in the meditation group, suggesting a differential effect detectable in both objective and subjective dimensions20. This contrasts with the only other published RCTs of meditation for asthma: In the first, conducted in 1975, TM was applied as part of the management of 25 asthma sufferers, but no between group comparisons were reported 21 while in the second, conducted in 1998, a multimodal yoga intervention that included meditative practices was compared to a waiting list control for 17 asthma sufferers. No between-group differences were found at post-intervention22. Looking beyond the confines of meditation, a systematic review of RCTS of relaxation therapies for asthma (including progressive relaxation, hypnotherapy, autogenic training, and biofeedback, but not meditation) concluded that there was no evidence for a positive effect on asthma management23. Manocha proposed that the findings of this trial may have resulted from fundamental differences between traditional eastern meditative practices, which strictly distinguish meditation as an experience of mental silence from the popular, more loosely defined westernized ideas of meditation as a method aimed at reducing physiological arousal. Reflecting the notion that a traditional, mental silence-orientated conceptualization of meditation might have effects distinct from simple reduction of arousal, a well-designed EEG study by Aftanas of established mental silence meditators demonstrated that, first, the practice is associated with reproducible patterns of brain electrical changes and, second, that these patterns meaningfully correlated with participants’ self –rating of the specifically-defined subjective experience24. Summarizing, it can be argued that the NCCAM’s shift in definition reflects the contrast between traditional eastern ideas of meditation as a state of transcendent, thought-free awareness and contemporary western scientific ideas of meditation as a form of relaxation. In this context, Manocha’s and Aftanas’ findings are notable because, first, they use a

traditional eastern, mental silence orientated form of meditation which is conceptually and experientially distinct from the contemporary western understanding of meditation, second, Aftanas’ reports that the subjective experience correlates highly with specific patterns of CNS activity, and third, Manocha reports significant therapeutic differences in a well-designed RCT comparison of this form of meditation versus a relaxation-orientated comparator. Since there is evidence to suggest that the conceptual differentiation implied in the NCCAM’s changing stance might reflect a biological distinction, further, more direct comparative exploration of these different conceptualizations is certainly warranted. Therefore in this exploratory study, since Rai appears to have identified change in ST as a potentially distinguishing factor, we compare ST changes during mental silence orientated meditation and rest.

2. Materials and Methods We compared advanced meditators with a convenience sample of non-meditators of similar age and gender who had strong interest in meditation and were willing to participate in a study about the effects of relaxation and meditation. Sixteen SYM practitioners with between 1 and 25 years of experience of daily meditation and 10 novices with no experience of meditation were recruited by advertisement in university newsletters. Exclusion criteria included regular alcohol, tobacco or recreational drug consumption, history of mental illness, current physical illness of any kind, a history of major physical illness and consumption of any regular prescription medication. In order to control for the most important factor, motivation, the novices were specifically selected for a high interest in learning meditation. Potential participants were promised that after the study they would be given a series of free instructional lessons in meditation. Participants sat in a moderately sized, quiet, climate-controlled room in a comfortable chair. The subjects were connected to the various sensors and then allowed to be become acquainted with the environment for 30 minutes, after which time a research assistant asked them if they were ready to commence the data collection session. When the participants indicated that they were ready, the lights were dimmed and the volunteers commenced either meditation or relaxation by closing their eyes. They were asked to either meditate or relax as best they could for the next 10 to 15 minutes. This time frame was selected because our preliminary trials found that meditators had difficulty sustaining the mental silence state for much longer in the laboratory

26

environment. At the end of the meditation or rest session, participants opened their eyes to indicate that they had finished.

ST was measured with a thermistor sensor affixed

to the palm of the nondominant hand. The thermistor was calibrated and accurate to 0.10ºC. HR was measured by a standard WR413 pulse oximeter. The change in skin temperature from baseline at each 60 second interval was calculated. Pulse oximeter with sensor placed on the middle finger of participants’ dominant hands. HR was recorded every 7 seconds and ST every 60 seconds.

Fig. 1 Skin Temperature Change Compared to

Baseline During Meditation X axis= time in minutes, Y axis= change degrees Celsius compared to baseline, triangle=rest group, square=SYM group

As this was an exploratory study the primary aim of analysis was to determine the direction of ST change that each subject manifested and whether or not there was any difference between the two groups in terms of this. Therefore we compared the number of subjects whose ST increased or decreased compared to baseline in each group at the end of the meditation session ie. Time (T)= 10 minutes.

Subjects were asked to give a general rating with regard to how they relaxed they felt at the beginning and at the end of the relaxation/meditation session using a linear analog scale. For the meditators the minimum value on the scale equated with normal thinking activity and the maximum value equated with profound mental silence. At T= 10 minutes, 13 of the 16 meditators

manifested a reduction in ST compared to their baseline value and 3 manifested an increase. Whereas in the rest group only 2 manifested a reduction, 7 manifested an increase in ST and 1 manifested no change.

3. Results Between the two groups There were no statistically significant differences in age, relative proportion of males/females or baseline ST and HR (Table 1). In line with our hypothesis, and to facilitate

statistical comparison, we classified subjects whose ST decreased during the meditation session as one category (ie comprising those whose ST changed in the opposite direction to that predicted by the reduced arousal model of meditation) and subjects whose a ST either increased or did not change as the opposing category (ie comprising those whose ST changed in the same direction predicted by the reduced arousal model of meditation, and the extant literature). We then compared the relative proportions of subjects in each of these categories between the two groups. 81.3% of meditators manifested a decrease in ST whereas only 20% of rest subjects manifested a decrease in ST. Statistical comparison using Chi-Square tests between these two categories and between the two groups showed that the difference between the two groups was significant (p=.003). (Table 2)

As the meditation session progressed mean ST of the two groups changed such that the rest group’s mean ST progressively increased compared to baseline whereas the SYM’s mean ST decreased compared to baseline (Fig. 1).

Table 1 Baseline Values. Age in years, HR in beats per minute, skin temp in degrees Celsius

Controls Meditators P value

Mean Age (sd) 28.5 (7.8) 29.0 (8.2) P=.887 (t=.144, df=25)

Sex (% male) 63.6% 62.5% P=.952 (χ2=.004, df=1)

HR (sd) 69.9 (15.2) 72.3 (9.5) P=.635 (t=.481, df=23)

ST (sd) 31.8 (1.4) 30.9 (2.4) P=.290 (t=1.08, df=24)

Table 2 Cross tabulation of Group by Difference

-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

1 2 3 4 5 6 7 8 9 10

Group N who manifested ST decrease

N who manifested ST increase

SYM 13 (81.3%) 3 (18.8%)

Rest 2 (20.0%) 8 (80.0%)

HR did not change consistently in any direction in either of the groups.

27

All subjects in both groups indicated that they felt more relaxed/meditative at the end of the session compared to the beginning. Degree of mental silence on the linear analog scale correlated significantly with degree of ST reduction in the meditator group (r=0.65, p<.05). Degree of relaxation experience did not correlate significantly with the degree of ST increase in the rest group.

4. Discussion Early studies of meditation suggested that basic physiological parameters could change quite dramatically in a single meditation session25, and this triggered considerable enthusiasm for meditation as a potentially unique self-control strategy. Later, however, high quality experimental physiological studies demonstrated minimal differences between meditation and other methods of reducing arousal, and researchers became much more cautious in their enthusiasm for this intervention 26 , 27 . Similarly, randomized, controlled, clinical trials of meditation have demonstrated minimal differences between meditation and appropriately selected controls, implying that while meditation may be clinically useful, it has no consistent features compared to rest/relaxation28. Despite the scientific establishment’s disaffection, surveys 29 and media attention 30 clearly show that the community’s enthusiasm for meditation continues to grow. Yet in this study, both groups of subjects performed tasks that ostensibly resembled relaxation and that would be conventionally explained as conducive to reducing arousal. Moreover, both groups reported subjective experiences which are consistent with reduced arousal. The reduced arousal model, and indeed empirical evidence, predicts that both groups should manifest similar physiological changes, with ST increasing. Our study found that ST moved in opposite directions despite the fact that the HR changes in the two groups did not differ across the duration of the task; The resting group’s skin temperature changes were consistent with reduced arousal, but the mental silence group’s were not. Thus, the changes produced by the meditation seem to reflect a pattern of selective arousal/de-arousal that is distinct from simple rest. Importantly, the findings of this study are in agreement with Rai’s report. Therefore both this study and Rai’s report are in contradiction with the extant scientific literature, counterintuitive at least from a western scientific perspective and are not easily explained in terms of simple, global reductions in arousal. They suggest that a mental silence orientated meditation may be physiologically distinguishable

from rest In this context, the findings of Manocha’s asthma trial warrant more detailed consideration. There are a number of theoretical difficulties associated with conventional understandings of meditation and relaxation, its influence on the autonomic nervous system (ANS), and its role in asthma management. For instance, relaxation strategies, in which meditation is conventionally included, are thought to reduce sympathetic tone and increase parasympathetic tone (i.e. reduce physiological arousal). Theoretically, however, reduced sympathetic tone should antagonize bronchodilation and, therefore, worsen symptoms and yet the experience of clinicians and scientific evidence suggests that stress (and other arousal increasing factors) often worsens asthma symptoms 31, 32. The notion that, since clinical experience has found that stress worsens asthma symptoms, stress reduction strategies should improve asthma symptoms is a consensus logic that is also challenged by the evidence. For instance, a comprehensive review of relaxation therapies for asthma by Huntley found that there was no clinical advantage in adding any form of relaxation to the management regime. Yet, despite all these contradictions Manocha reports significant changes not only in symptomatology but also in direct measures of disease severity when using a mental silence form of meditation. Perhaps a selective activation/deactivation of the ANS may better explain both the clinical and physiological phenomena associated with this approach to meditation and its effects in asthma. The health benefits of meditation are frequently associated with traditional Eastern ideas of yogic physiology such as chakras, nadis and energies like kundalini. The founder of SYM explains the phenomenon using a similar “yogic physiology” paradigm 33 . Rai asserts that these ideas correlate closely with modern physiological understandings of the Autonomic Nervous System but that SYM somehow elicits a unique pattern of activity within this system34. EEG studies suggest that different approaches to meditation have different neurophysiological bases. For example, a study of advanced Tibettan Buddhist meditators reported large increases in 40Hz gamma power in the meditative state35 and it is also advanced Tibetan meditators whom Benson described as manifesting considerable increases in ST. Whereas Aftanas’s EEG study of advanced mental silence meditation practitioners 36 reported that midline alpha-theta power, rather than gamma power, increased strongly in direct positive correlation with self reported meditative experience and negative

28

correlation with thought appearance rates. Mental silence is the defining feature of SYM and arises as a result of the meditator’s ability to not only avoid initiating thoughts that may arise as a reaction to events (as in mindfulness 37 ) but to completely eliminate even the “background mental noise”. In other words, mindfulness may be defined as a state in which one passively observes the ebb and flow of thoughts while not getting involved with them, the SYM practitioner seeks to unite their awareness with the “space between the thoughts” and then expand this dimension of the meditative experience, reaching a unique clarity of awareness. Hence the definition of SYM is orientated around a specific state of consciousness and is therefore “experience-orientated” rather than “attention-orientated” (as in mindfulness) or “relaxation-orientated” ( as in Benson’s Relaxation Response38). It is important to note here that we are not suggesting that any particular technique is superior to any other, merely the possibility that the mental silence definition might provide a convenient framework to categorise various techniques as we search form meaningful ways to understand this particular independent variable. Goleman posits the notion that meditative styles might be classified into two types, mindfulness and concentrative, depending on how attention is directed during meditation 39 while Andresen suggests that these two categories might be better understood as two poles on a continuum upon which most other meditative techniques can be positioned 40 . On the other hand Cahn acknowledges the limitations of this taxonomy and raises the possibility that a different way of categorizing techniques may be according to the underlying experience that the various techniques aim to elicit41. In this context mindfulness and mental sielnce may belong to similar places on the physiological and clinical spectrum whereas relaxation orientated methods might belong to an entirely different part of that spectrum. In general, meditation’s mechanism of action is thought to primarily involve its ability to reduce stress. There are two main theories about how meditation reduces stress: First, by reducing somatic-arousal42, thereby reducing reactivity of the individual to environmental stressors, and , second, by altering the individual’s cognitive appraisal of and perceived self efficacy with regard to stressors 43 , 44 . The mechanisms by which the mental silence experience exerts its purported clinical effects are unclear. Notably, practitioners of SYM consistently report that the state of inner silence spontaneously gives rise to concomitant phenomena such as a natural focusing of

attention, a sense of mental wellness and therefore elimination of negative affect and improved physical health. Although mental activity has been eliminated it can be initiated at any time with the added advantage that the “background mental noise” no longer hinders cognitive activity. The idea that this constellation of changes might occur “spontaneously” implies that involuntary pathways are at least partly involved even at the higher function level. By completely eliminating background mental noise, the meditator probably increases internal and external awareness and therefore somehow achieves more veridical perception, reduce negative affect and improve vitality and coping, as is hypothesized with mindfulness 45. Given that the mental silence experience may be associated with a specific pattern of activity in both the CNS and ANS, more complex, as yet unknown mechanisms may await discovery. Assume for argument’s sake that the physiological differences apparently demonstrated here between SYM and rest reflect the conceptual differences between meditation as mental silence and meditation as relaxation. This may then support Manocha’s explanation for the significant outcomes reported in the asthma trial previously mentioned while also explaining why other trials of meditation, relaxation and biofeedback did not generate similar outcomes for the same condition. One might therefore speculate that the difficulties faced by researchers trying to identify a consistent difference between meditation and rest may be related to western scientists’ (mis)understanding of the phenomena as a method of inducing the relaxation response (the NCCAM’s pre-2006 definition) rather than as a specific experiential state, the traditional eastern idea of “mental silence” (more or less implied in the NCCAM’s new definition). Thus, although eastern and western ideas of meditation may seem externally similar (as might meditation and relaxation) and may initially share a number of physiological similarities, a measurable physiological distinction may occur in association with the onset of the mental silence experience. The degree to which this physiological distinction explains the differing clinical effects between traditional and contemporary ideas of meditation and relaxation remains to be determined. Manocha’s asthma trial however clearly suggests that the distinction may have considerable clinical relevance. Perhaps popular perceptions of meditation as being good for health are based on traditional eastern notions of the practice involving the mental silence experience, which have formed the basis of traditional anecdote and folklore, whereas the contemporary scientific understanding of meditation is based on the

29

western notion of psychophysiological equivalence with rest/relaxation. Does the lack of emphasis on the mental silence experience in contemporary scientific understandings of meditation offer an explanation for its poor performance in experimental conditions and hence the discrepancy between popular perception and current scientific facts? Practitioners of this technique described a subjective sense of cooling of the hands during meditation. The objective ST measures appear to support this. While the skin temperature changes appear real, to what degree are they the result of suggestion/self regulation as opposed to meditation specifically? A review by King 46 reported that biofeedback has been shown to induce both increases and decreases of skin temperature. Although the changes induced by biofeedback are generally small and more commonly involve increases in skin temperature, reductions in skin temperature are also consistently achievable. In addition, the empirical evidence for reducing skin temperature by self regulation (unassisted by biofeedback), although less consistent, also suggests that such changes might be achievable. The fact that the meditators in this trial were long-term practitioners raises the possibility that they may be a subgroup highly selected for their ability to voluntarily induce such changes. On the other hand, regarding techniques that are similar but not labeled as meditation, Credidio (1982)47 attempted to produce a patterned biofeedback response that mimicked the multiple changes associated with reduced physiological arousal. The study failed to produce a combined electromyograph (EMG) reduction and ST increase, suggesting that the achievement of the full constellation of changes in multiple parameters reported in the trials of Rai, Manocha and Aftanas would be very difficult to achieve.

5. Conclusion Perhaps because of the rising popularity of techniques such as mindfulness and the more eastern ideas about meditation that it embodies, in 2006 the NCCAM revised its definition to include the idea of “suspension of usual thought activity” and to de-emphasize the significance of relaxation, raising important questions about whether or not this shift in conceptualization may also imply a different biological paradigm as well. This study is unique as it compares the physiological differences between the two conceptually different taxonomies of meditation that the NCCAM’s change in definition implies. It provides preliminary support for a distinction between mental silence orientated meditation and rest with

promising implications for the field of meditation research. Further research is necessary to determine whether or not this distinction might have practical implications for health professionals. Larger studies with both multiple control groups and multiple measures are needed to further assess, first, whether or not the changes in ST are a specific effect relating to the experience of mental silence, and, second, the precise relationship between these physiological changes and the apparent therapeutic effects reported in other studies of mental silence orientated meditation.

Acknowledgements The authors gratefully acknowledge the Swinburne University’s Psychophysiology Laboratory and the Sahaja Yoga meditators of Australia who offered their support without charge. The authors also acknowledge the founder of the modern Sahaja Yoga technique, Shri Mataji Nirmala Devi, who permits its use in scientific research on the proviso that it not be commercialized. The authors did not develop the Sahaja Yoga method and declare that they have no financial conflict of interest in this study

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Non-linear dynamic complexity of the human EEGduring meditation

L.I. Aftanas*, S.A. Golocheikine

Psychophysiology Laboratory, State-Research Institute of Physiology, Siberian Branch, Russian Academy of Medical Sciences,

Timakova str. 4, 630117, Novosibirsk, Russia

Received 28 May 2002; received in revised form 1 July 2002; accepted 2 July 2002

Abstract

We used non-linear analysis to investigate the dynamical properties underlying the EEG in the model of Sahaja Yoga

meditation. Non-linear dimensional complexity (DCx) estimates, indicating complexity of neuronal computations, were

analyzed in 20 experienced meditators during rest and meditation using 62-channel EEG. When compared to rest, the

meditation was accompanied by a focused decrease of DCx estimates over midline frontal and central regions. By

contrast, additionally computed linear measures exhibited the opposite direction of changes: power in the theta-1 (4–

6 Hz), theta-2 (6–8 Hz) and alpha-1 (8–10 Hz) frequency bands was increased over these regions. The DCx estimates

negatively correlated with theta-2 and alpha-1 and positively with beta-3 (22–30 Hz) band power. It is suggested that

meditative experience, characterized by less complex dynamics of the EEG, involves ‘switching off’ irrelevant networks

for the maintenance of focused internalized attention and inhibition of inappropriate information. Overall, the results

point to the idea that dynamically changing inner experience during meditation is better indexed by a combination of

non-linear and linear EEG variables. q 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: EEG; Dimensional complexity; Non-linear dynamics; EEG band power; Meditation

The application of non-linear system theory to the EEG

has been shown to offer new ways of analyzing neural regu-

lation at a gross (mass action) level [4,12,20]. According to

Hebb’s view of neuron assemblies as functional processing

units, in the working brain there may be not only one or two,

but a much larger number of cell assemblies oscillating

synchronously at different frequencies. In this case the

number of cell assemblies activated can be considered as

an indicator of complexity of neuronal computations in the

brain [4,8]. The geometrical measure, EEG dimensional

complexity (DCx), derived from non-linear system theory,

has been often calculated in order to elucidate the key

aspects of brain dynamics such as overall complexity

[4,12]. The dimension calculated from EEG time series

has been shown to be a monotonically increasing function

of the number of independent neural processes [8]. This

implies that the calculated dimension value in different

tasks can, in principle, be related to the number of neural

assemblies active simultaneously in the brain [8,12].

DCx estimates have also been used as evidence of non-

linearity and possible nonlinear determinism (deterministic

chaos of the strange-attractor type) of EEG signal mostly

without any proof (for review see Ref. [4]). However,

special works have shown that the values of this measure

in linearly-correlated noise are very similar to those

obtained from a system clearly chaotic in nature [15].

Results of subsequent investigations with surrogate data

tests indicated that EEG was not produced by low-dimen-

sional chaos; however, it was non-linear (for a short review

see Refs. [12,13]). Nonetheless, estimated EEG DCx

provides a valuable relative, generic measure of the dyna-

mical complexity of a time series regardless of the source of

the complexity (chaos, linear and nonlinear stochasticity)

[2,4,7,9,10,16,17]. Thus, the issues of non-linearity in

general and low-dimensional chaos in particular are sepa-

rate from the issue of utility of estimated DCx as an EEG

measure [13] (p. 487). Of special note are variations in scalp

distribution of DCx estimates of discriminating perception

and imagery processes [7,17], different attentional [9] and

emotional [2] states, and creative and convergent thinking

modes [10].

The present study was undertaken to examine how dyna-

Neuroscience Letters 330 (2002) 143–146

0304-3940/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved.

PII: S0304-3940(02)00745-0

www.elsevier.com/locate/neulet

* Corresponding author. Tel.: 17-3832-334387; fax: 17-3832-

324254.

E-mail address: [email protected] (L.I. Aftanas).

mically changing inner experience during meditation is

indexed by EEG DCx estimates. Findings from our earlier

investigation show that meditation was accompanied by

theta and alpha synchronization as well as enhanced theta

long-distance connectivity [1]. Considering the existence of

inverse correlational relationships between DCx estimates

and EEG power mainly in lower frequency bands [19,20],

the prediction was that meditation would be accompanied

by less complex dynamics.

This study is essentially a reanalysis of the data from our

previous EEG investigation of Sahaja Yoga meditation [1],

which is a model of conscious mental process, characterized

by internalized attention and emerging emotionally positive

experiences. The key experience during Sahaja Yoga medi-

tation is a state called ‘thoughtless awareness’ or ‘mental

silence’ in which the meditator is alert and aware but is free

of any unnecessary mental activity. The state of ‘thoughtless

awareness’ is usually accompanied by emotionally positive

experience of ‘bliss’. In general, the outcome of the medi-

tative process is associated with a sense of relaxation and

positive mood and a feeling of benevolence towards oneself

and others [14]. The EEG was recorded during the eyes

closed rest and meditation condition. Scan 4.1.1 software,

a 128-channel ESI System (ESI-128, NeuroScan Labs.) and

64-channel QuikCap with imbedded Ag/AgCl electrodes

(NeuroSoft, Inc.) were used to record EEG from 62 active

scalp sites referenced to the tip of the nose along with both

vertical and horizontal EOGs. Three artifact free EEG

segments by 8.192 s (i.e. 4096 points) were selected for

each condition (for details see Ref. [1]). In contrast to

previous investigations, some modifications were

performed: (1) since reliable effects of meditation on the

EEG activity were obtained only in experienced meditators,

short-term meditators were not included in the analysis; (2)

four recently recorded experienced meditators were

included for analyses so the total sample of subjects reached

20 right-handed subjects (males, n ¼ 9; females, n ¼ 11)

between the ages of 20 and 40 years who were regularly

practicing meditation.

For the present study, the EEG segments were prelimin-

ary bandpass filtered (4–30 Hz) by means of an acausal filter

and subjected to non-linear analysis. Using the licensed

algorithm [18] we calculated the mean PD2i estimate,

based on the averaged serial PD2i slopes found for the 9th

through 12th embeddings (M) with the associated standard

deviations (for details see Refs. [2,18]). For linear analyses

the same EEG segments were epoched into two 4096 ms

(i.e. 2048 points) epochs, fast Fourier transformed (FFT)

and averaged in the frequency domain using a Parzens

window. The FFTs were then grouped into the theta-1 (4–

6 Hz), theta-2 (6–8 Hz), alpha-1 (8–10 Hz), alpha-2 (10–12

Hz), beta-1 (12–18 Hz), beta-2 (18–22 Hz) and beta-3 (22–

30 Hz) frequency bands, log-transformed, and averaged

across three EEG traces.

Lateral electrodes were collapsed into eight electrode

clusters. This procedure resulted in four regional means

for each hemisphere: anterio-frontal (AF), fronto-central

(FC), centro-parietal (CP) and parieto-occipital (PO). Elec-

trodes of the midline were also collapsed into four electrode

clusters: anterio-frontal (mAF - AFz, Fz), fronto-central

(mFC - FCz, Cz), centro-parietal (mCP - CPz, Pz), and

parieto-occipital (mPO - POz, Oz) zones (Fig. 1). Power

values and DCx estimates over individual electrodes were

averaged to form regional means. DCx estimates for

symmetrical cortical regions were subjected to four-way

repeated measures ANOVAs, involving factors of Condi-

tion (COND: rest, meditation), Hemisphere (HEM: left,

right), Caudality (CAUD: anterior, posterior) and Localiza-

tion (LOC: 2). For midline regions three-way ANOVAs

(COND (2) £ CAUD (2) £ LOC (2)) were applied. All

analyses were followed by post-hoc comparisons (Scheffe

test). Degrees of freedom were Greenhouse–Geisser

corrected where appropriate.

ANOVAs of DCx estimates for symmetrical regions

revealed no effects of meditation. By contrast, ANOVAs

for midline regions resulted in significant COND £ CAUD

interactions (Fð1; 19Þ ¼ 8:60, P , 0:009). Inspection of

respective means of this interaction (Fig. 2) points to

decreased DCx during the meditation condition over

midline anterior cortical regions.

Since effects of meditation were associated with midline

regions, only spectral power values from these regions were

subjected to repeated measures ANOVAs. Among seven

frequency bands theta-1, theta-2, alpha-1 and alpha-2

bands revealed effects associated with the meditation condi-

tion (Fig. 3). According to a significant COND £ CAUD

interaction (Fð1; 19Þ ¼ 9:44, P , 0:006) for the theta-1

L.I. Aftanas, S.A. Golocheikine / Neuroscience Letters 330 (2002) 143–146144

Fig. 1. The electrocap layout and 12 electrode clusters (eight

lateral: AF, FC, CP, and PO for the left and right hemispheres;

four midline: mAF, mFC, mCP, and mPO).

band, meditation was accompanied by a power increase

over anterior midline regions. The significant effect of the

factor of COND (Fð1; 19Þ ¼ 6:26, P , 0:022) for the theta-

2 band points to the overall increase of power during medi-

tation, which, however, was slightly more pronounced over

anterior regions. As indexed by the interaction COND £

CAUD (Fð1; 19Þ ¼ 5:40, P , 0:031) for the alpha-1 band,

meditative experience yielded a power increase over ante-

rior midline regions. Finally, as evidenced by the interaction

COND £ CAUD £ LOC (Fð1; 19Þ ¼ 4:55, P , 0:046), in

the alpha-2 band meditation induced focused power

increase over the posterio-occipital (mPO) region.

Correlational analyses of DCx estimates and spectral

power values from anterior midline regions revealed signif-

icant relationships among them during the meditation condi-

tion: DCx estimates negatively correlate with theta-2 (range

from r ¼ 20:52 to r ¼ 20:57) and alpha-1 (range from r ¼

20:56 to r ¼ 20:66), and positively with beta-3 (range

from r ¼ 20:55 to r ¼ 20:59) band power.

Summarizing, the effects of meditation were differen-

tially reflected by local EEG DCx, theta and lower alpha

band power changes.

As mentioned above, in this paper changes in DCx are

considered as changes in the complexity of neuronal compu-

tations. During the meditation condition significant changes

of dynamical complexity were manifested as a focused

decrease of EEG DCx estimates over midline anterio-frontal

and centro-frontal regions. There are several findings indi-

cating that DCx of the EEG from frontocortical regions is

negatively correlated with attentional control (effort) over

cognitive processing. Increased attentional control [9] was

accompanied by decreased DCx, whereas different normal

and pathological brain states of loosened attention such as

imagery [7,17], divergent thinking mode [10] or schizophre-

nia [16] were associated with increased DCx over fronto-

cortical regions. The finding of lower DCx over midline

frontal areas during meditation suggests that controlled allo-

cation of attentional resources was required for the main-

tenance of the target meditative state and the inhibition of

inappropriate stimuli. The reduction of the dimensionality

might be an expression of strongly coupled oscillators or the

inactivation of previously active networks [8]. It is quite

possible that this effect is influenced by activities of the

cingulum, which is involved in the meditation process

[11]. One may assume that meditative experience accom-

panied by decreased DCx involves ‘switching off’ irrelevant

networks for the maintenance of focused internalized atten-

tion and inhibition of inappropriate information. To some

extent, the obtained findings fit the preliminary statement by

Elbert et al. [4], according to which “…the task performance

increases dynamical complexity over those brain areas with

little involvement in the task, but reduces the DCx in those

areas in which networks became actively engaged” (p. 35).

As for the linear measures, the revealed theta-2 power

increase over anterior midline electrodes may reflect recruit-

ment of theta oscillating networks in focused attention

mechanisms [1,3,5,6] associated with meditative process.

A possible interpretation of lower alpha power changes

L.I. Aftanas, S.A. Golocheikine / Neuroscience Letters 330 (2002) 143–146 145

Fig. 3. Mean values of theta-1, theta-2, alpha-1, and alpha-2 EEG

band power over the midline cortical regions for the eyes closed

rest and meditation conditions. *P , 0:05; **P , 0:01 (post-hoc

comparisons, Scheffe test).

Fig. 2. (1) Maps representing the topographical distribution of

the mean values of EEG DCx estimates for the eyes closed and

meditation conditions. (2) Map of differences between rest and

meditation conditions. (3) Mean values of EEG DCx estimates

over the midline cortical regions for the eyes closed and medita-

tion conditions. *P , 0:05 (post-hoc comparisons, Scheffe test).

during meditation may be ascribed to functional heteroge-

neity of different alpha frequency bands. According to a

variety of experimental paradigms, desynchronization in

the lower alpha band reflects processes of external attention

such as alertness/vigilance (e.g. Ref. [6]). One may assume

that meditative experience is mediated by ‘switching off’

mechanisms of external attention as indexed by enhanced

alpha-1 synchronization over anterior cortical regions. It is

very indicative that inverse correlations of DCx estimates

with theta and lower alpha band power, seen in cognitive

experimental paradigms [19], were selectively obtained for

cortical regions involved in the meditative process. Finally,

high band power, which did not yield significant changes

during the meditation condition vs. rest, did reveal signifi-

cant positive correlations with DCx estimates. The nature of

these correlations, indicating that lower complexity is

accompanied by lower beta-3 power values during medita-

tion, needs further clarification.

Overall, the results point to the idea that dynamically

changing inner experience during meditation are better

indexed by a combination of linear and non-linear EEG

variables, giving additional insight into the integrative func-

tioning of the CNS with respect to altered states of

consciousness.

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tors, Phys. Rev. E, 47 (1993) 2289–2297.

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Pascual-Marqui, R.D., Kochi, K., Wackermann, J. and

Lehmann, D., Global, regional, and local measures of

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acute, neuroleptic-naive, first-break schizophrenics, Biol.

Psychiatry, 43 (11) (1998) 794–802.

[17] Schupp, H.T., Lutzenberger, W., Birbaumer, N., Miltner, W.

and Braun, C., Neurophysiological differences between

perception and imagery, Cogn. Brain Res., 2 (1994) 77–86.

[18] Skinner, J.E., Molnar, M. and Tomberg, C., The point corre-

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gate data and noise, Integr. Physiol. Behav. Sci., 29 (1994)

217–234.

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L.I. Aftanas, S.A. Golocheikine / Neuroscience Letters 330 (2002) 143–146146

Meditation, mindfulness and mind-emptiness

Meditation is widely perceived as aneffective method for reducing stress andenhancing wellbeing. The US Centers forDisease Control and Prevention’s 2002National Health Interview Surveyadministered to 31 000 representativeadults showed that 8% of respondents hadpracticed meditation at some time (1). TheAustralian Community Survey found that1.5 million Australians had triedmeditation in the past 12 months and thatwhile 29% of Australians found prayer tobe a source of peace and wellbeing, 24%used meditation for the same thing.Remarkably, despite the fact that onlyabout 20% of Australians attend churchmonthly or more often, around 33% ofAustralians pray or meditate at leastweekly (2,3).

Health professionals are alsoenthusiastic about meditation, despite alack of formal education about it; a surveyof Australian general practitioners (GPs)found that almost 80% of respondents hadrecommended meditation to patients atsome time in the course of their practice,yet less than 35% had any formal trainingor education in the field (4). Mindfulnesshas become particularly popular in recentyears both among consumers and healthprofessionals.

The conundrum

Although more than 3000 scientific studieshave been published on meditation withinthe English-speaking peer-revieweddatabases, only about 4% are reports onrandomised controlled trials (RCTs) – theonly way to reliably exclude the placeboeffect. High-quality reviews of these RCTsconsistently find that meditation, as it ispractised and defined in western society(e.g. relaxation, attention focusing and

mindfulness), is little more than asophisticated way of generating anon-specific effect (5).

In other words, meditation as it iscurrently understood does not give betterresults than taking a short nap, listening topleasant music or thinking pleasantthoughts. This logically calls into questionthe expense and/or effort that manymeditation methods entail. Furthermore, italso questions the cultural and historicalexpectations that have come to surroundmeditation.

The mismatch between the scientificevidence, consumer enthusiasm andperceptions embedded in the widernoosphere creates a conundrum forprofessionals seeking to make responsiblerecommendations in practice.

We propose that these conflictingnotions about meditation can bemeaningfully resolved by changing itsdefinition to bring it in closer alignmentwith its ancient origins.

Ancient clues

Modern science most commonlycharacterises meditation as a relaxationresponse or a pattern of specificallyfocused attention. These conceptualisationsdiffer fundamentally from the authenticdescriptions of the meditative experienceoriginating in ancient India. The originalsource texts clearly state that a keydefining feature of meditation is theexperience of mental silence. For example,in what is probably the oldest knowndefinition of meditation, the narratorexplains in the ancient Indian Mahabharatathat a meditator is ‘. . . like a log, he doesnot think’ (6). Similarly, Lao Tse instructsthe reader in the Tao Te Ching to ‘emptythe mind of all thoughts’. Many other

explicit examples of this idea can be foundin Eastern literature from virtually everyhistorical period. Yet Western definitionsof meditation have consistently failed toacknowledge this crucial feature. Perhapsthis is because of the predominance of theCartesian dictum ‘cogito ergo sum’(I think therefore I am) that has come tocharacterise Western philosophy.

Evidence

The Meditation Research Program (MRP)is specifically interested in scientificevaluation of the mental silencephenomenon. Our findings so far suggestthat it is associated with a detectablespecific effect. For example, a rigorousRCT of sahaja meditation (a techniquetypified by the experience of mentalsilence) for occupational stress showedsignificantly superior effects on measuresof work-related stress and depressivefeelings (7) when compared to an activecontrol. Another RCT showed specificeffects on asthma-related parameters (8).Other trials conducted elsewhere alsoshow promisingoutcomes.

In both RCTs, mental silence appears togenerate an improvement in psychologicalparameters and aspects of quality of lifethat is clinically and statistically greaterthan that seen with more conventionalstress management. There is also someevidence that aspects of physical diseaseprocesses may also be significantlyimpacted. This is the subject of ongoingresearch.

Psychophysiology of mental silence

A well-designed electroencephalographic(EEG) study reported that the experience

1

is consistently associated withsymmetrically distributed fronto-parietalmidline alpha/theta activity. Perhaps mostremarkable was the strong correlationbetween subjective quality ofself-reported meditative experienceand the strength of these electricalchanges (9).

Further, a remarkable althoughpreliminary study of experiencedmeditators compared to a matched controlgroup asked to relax demonstrated thatwhile heart rate changes in both groupswere not different, the skin temperature ofthe meditators paradoxically fell ratherthan increased. The degree of skintemperature change correlated stronglywith the meditator’s self-reported qualityof mental silence experience. Thiscontradicts the relaxation response modeloften used to explain the effects ofmeditation (10).

Taken together these studies create apicture suggesting that the mental silenceexperience may be associated with aspecific pattern of central and peripheralphysiological activities. Whether or notthese changes explain the specific effectsobserved in the clinical studies remains tobe determined.

Practical ramifications

First, all approaches to meditation, be theyrelaxation, mindfulness, contemplative orwhatever, are associated with beneficialnon-specific effects as are all stressmanagement style interventions. Second,however, mental silence-orientatedapproaches to meditation may beassociated with additional, specific effectsthat are clinically beneficial. Third, thebeneficial impact of meditation is notrelated to its cost. In fact, non-commercialapproaches to meditation, especially ifthey involve mental silence, may bepreferable.

Mindfulness and mind-emptiness

Finally, the principle of mental silencerepresents an important progression on themindfulness concept. It is important toremember that mindfulness methodologywas most explicitly laid out in Buddhistmeditation texts, yet the practice ofmeditation and the notion of mentalsilence predates ideas of mindfulness bysome thousands of years. The practice ofmindfulness essentially involves thepassive observation of internal and

external stimuli without mental reaction.Mental silence is a logical progression ofthis principle wherein the meditator notonly observes their mental content withoutreaction but in fact attains a state of nomental content at all, while remaining infull control of their faculties.

The practical experience in our clinicaltrials bears this notion out since we foundthat mindfulness strategies were oftenuseful to facilitate mind-emptiness. Wepropose that mindfulness was in factdeveloped with the intention of facilitatingthe experience of mental silence.Mindfulness may be better understood as ameans to an ends rather than being anends in itself.

Towards a new taxonomy

The notion of mental silence as thedefinitive meditative state logicallysuggests that contemplative and meditativepractices could be unified in a singletaxonomy based on mental activity.Within this schema, it may be possible toposition meditative methods on a spectrumaccording to the way in which they areintended to modulate thinking. At the highend of the thinking activity spectrumwould be methods such as prayer andvisualisation. At the other end would bemental silence-orientated techniques suchas sahaja and Zen. Midway would berelaxation methods which, by reducingarousal, might reduce mental activity moreso than prayer or visualisation, but not asmuch as, say, mantra-based meditationthat focuses on a single syllable or word.Mindfulness might be positioned towardsthe mental silence end, just before thosetechniques that specifically focus onmental silence itself. Extrapolating on thisconcept, methods at the ‘high mentalactivity’ end of the spectrum will beassociated with non-specific effects, whilethose at the ‘low mental activity’ endmight be more likely to be associated withspecific effects. Although possiblyover-simplistic this novel perspectiveoffers a practically meaningful way ofcontextualising the otherwiseheterogeneous and sometimescontradictory methods that claim ahome under the rubric of meditation.

In conclusion, the mental silenceparadigm might offer not only a morehistorically authentic approach tomeditation but also a resolution to some ofthe crucial paradoxes associated with thegenre with beneficial implications forclinicians and the community.

Ramesh Manocha

Department of Psychiatry, Northern Clinical School,Royal North Shore Hospital, University of Sydney,

Sydney, Australia

Dr Ramesh Manocha,Senior Lecturer, Department of Psychiatry,

Northern Clinical School, Royal North Shore Hospital,University of Sydney,

Sydney, Australia.Tel: +612 9926 7787Fax: +612 9926 7730

E-mail: [email protected]

Acta Neuropsychiatrica 2011© 2011 John Wiley & Sons A/SDOI: 10.1111/j.1601-5215.2010.00519.x

References

1. Barnes PM, Powell-GrinerE, McFann K, Nahin RL.Complementary and alternative medicineuse among adults: United States, 2002.Adv Data. 2004; 343:1–19.

2. Kaldor P, Bellamy J, Powell R.Australian Community Survey. Build mychurch: trends and possibilities forAustralian churches. Adelaide: Openbook,1998.

3. Bellamy J, Castle K. Church attendanceestimates. NCLS occasional papers.Sydney: National Church Life Survey,2001.

4. Pirotta MV, Cohen MM, Kotsirilos V,Farish SJ. Complementary therapies: havethey become accepted in general practice?Med J Aust 2000;172:105–109.

5. Ospina M, Bond T, Karkhaneh M et al.Meditation Practices for Health: State ofthe Research. Evidence Report/TechnologyAssessment No. 155. Rockville:Healthcare Research and Quality, 2007.

6. Feuerstein G. Yogic meditation. In:Shear J, ed. The experience ofmeditation: experts introduce the majortraditions. St Paul: Paragon House, 2006:87–117.

7. Manocha R. A randomised controlledtrial of mental silence meditation for workstress. 10th International Congress ofBehavioural Medicine, Tokyo, Japan,August 27–30, 2008.

8. Manocha R, Marks GB,Kenchington P, Peters D, Salome CM.Sahaja Yoga in the management ofmoderate to severe asthma: a randomisedcontrolled trial. Thorax 2002;57:110–115.

9. Aftanas L, Golocheikine S. Non-lineardynamic complexity of the human EEGduring meditation. Neurosci Lett2002;330:143–146.

10. Manocha R. Does meditation have aspecific effect: a systematic experiemntalevaluation of a mental silence orientateddefition. Doctoral Thesis, UNSW, 2008.

2

EFFECT OF SAHAJ YOGA ON NEURO-COGNITIVE FUNCTIONSIN PATIENTS SUFFERING FROM MAJOR DEPRESSION

V. K. SHARMA#*, S. DAS, S. MONDAL**, U. GOSWAMI***AND A. GANDHI**

*Department of Physiology,Vardhaman Mahavir Medical College,New Delhi – 110 029

and

Departments of **Physiology and ***Psychiatry,Lady Hardinge Medical CollegeNew Delhi – 110 001

( Rece ived on September 7 , 2005 )

Abstract : Cognitive functions are impaired in Major Depression. Studieson the effects of Yoga on cognitive functions have shown improvement inmemory, v igi lance and anxie ty levels . 30 pat ients suffer ing f rom Majordepression (age 18 to 45 years) were randomly divided into two groups:Group 1: (10 males and 5 Females) Pat ients who prac t i sed Sahaj Yogameditation and also received conventional anti-depressant medication. Group2: (9 males and 6 Females) Patients who only received conventional anti-depressan t medica t ion . Group 1 pa t ien ts were adminis te red Saha j Yogaprac t ice fo r 8 weeks . Neuro-cogni t ive t es t ba t t e ry cons i s t ing o f Le t te rcancellation test (LCT), Trail making test ‘A’ (TTA), Trail making test ‘B’(TTB), Ruff figural fluency test (RFFT), Forward digit span (FDS) & Reversedig i t span tes t (RDS) was used to assess fo l lowing cogni t ive domains :Attent ion span, v isuo-motor speed, shor t - term memory, working memoryand executive functions. After 8 weeks, both Group 1 and Group 2 subjectsshowed significant improvement in LCT, TTA & TTB but improvement inLCT was more marked in Group 1 subjects . Also, there was s ignif icantimprovement in RDS scores in only Group 1 subjects (P<0.05). The resultsthe reby , demons t ra te tha t Saha j Yoga p rac t i ce in add i t ion to theimprovement in var ious o ther cogni t ive domains seen wi th convent ionalanti-depressants, can lead to additional improvement in executive functionslike manipulation of information in the verbal working memory and addedimprovement in at tention span and visuo-motor speed of the depressives.

Key words : sahaj yoga major depression neuro-cognitive functions

Ind ian J Phys io l Pharmaco l 2006 ; 50 (4 ) : 375–383

*Cor respond ing Author : E-mai l : d rv iveksharma@yahoo .com

INTRODUCTION

Major depress ive d i sorder (Unipo la rdepress ion) i s the mos t common mood

disorder and is ranked fourth in the l ist ofthe most urgent heal th problems worldwideby W.H.O. with the life t ime prevalence ofdepressive disorders of around 10–25% for

376 Sharma et al Indian J Physiol Pharmacol 2006; 50(4)

women and 5–12% for men (1). The associatedcogni t ive def ic i ts are f requent ly viewed asepiphenomena of the disorder and cognitiveimpai rment i s l ike ly to be a key fac toraf fec t ing the subjec t ’s ab i l i ty to func t ion .Cognitive changes in depression span a rangeof functions, including deficiency in sustaineda t ten t ion , concen t ra t ion , se t main tenance ,efficiency of information processing, verbal& non-verba l long te rm memory , shor tt e rm re ten t ion , v i suo-spa t ia l sk i l l s andconstructional abil i ty (2).

The sc ience of Yoga deals wi th a manholistically, as this is the only science, whichtakes in to cons idera t ion both the ‘psyche’and the ‘soma’ aspects of human framework.Study on the effects of Yoga on cogni t ivefunc t ions has shown improvement inmemory, v igi lance & anxiety (3 , 4) . SahajYoga is a form of “Kundalini Yoga” whichdescr ibes a s imple technique to arouse thela ten t po ten t ia l o f man by a s implemedi ta t ive process . Sahaj Yoga has shownbenef ic ia l e f fec t in the management o fHyper tens ion , Bronchia l as thma (5) andepi lepsy (6) . Previous scient i f ic s tudies onSaha j Yoga have a l so demons t ra ted i t sro le in reduc t ion in anx ie ty l eve l s (7 ) ,improvement in sensory-motor funct ioning,reac t ion t ime (8) and be t te r au tonomiccont ro l (9 ) in hea l thy prac t i t ioners .However, executive functions have not beenstudied yet and there is paucity of data ofthe e f fec t s o f Saha j Yoga on cogni t ivefunc t ions in pa t ien t s o f Major Depress ionin whom these func t ions a re a f fec ted .Therefore the a l t e rna t ive approaches i . e .Saha j Yoga wi th po ten t ia l cogni t iveenhancement e f fec t s , i f any , have beenexplored in this study.

METHODS

The present study was carried out in theDepar tment o f Phys io logy and Depar tmentof Psychiatry, Lady Hardinge Medical Collegeand Smt . Suche ta Kr ip lan i Hospi ta l ,New Delhi .

Study des ign

Thi r ty pa t ien t s suf fe r ing f rom MajorDepression (19 Males & 11 Females) in theage group of 18–45 years were recruited fromout pa t ien t se rv ices o f the Depar tment o fPsychiatry, S.S.K.H. and the diagnosis wasconfirmed independently by two psychiatristsusing DSM-IV criteria.

Inc lus ion cr i ter ia

(i) Pat ients in the age group of 18 to 45years u t i l i z ing the se rv ices o f theDepar tment o f Psychia t ry , LadyHard inge Medica l Col lege wi th thediagnoses of Major Depression accordingto DSM-IV criteria.

(ii) At least six years of formal education.

(iii) Had no t been t rea ted fo r the cur ren tepisode of Depression.

Exclus ion cr i ter ia

(i) Pa t ien t s wi th h i s to ry of p rev ious o rcurrent organic d isease .

(ii) Pa t ien t s wi th pas t h i s to ry o r cur ren tevidence of substance dependence.

(iii) Pa t ien t s wi th ep i lepsy or menta lr e t a r d a t i o n .

Ind ian J Phys io l Pharmaco l 2006 ; 50(4 ) Sahaj Yoga and Major Depression 377

(iv) Patients who were unwill ing or unableto par t ic ipate .

Drop out cr i ter ia

(i) Withdrawal of consent .

(ii) Exacerbation of symptoms/emergence ofnewer symptoms.

Exper imenta l des ign

All the pa t ien t s were the randomlydivided into following groups-

GROUP 1 (n=15) (10 Males and 5Females ) 15 d iagnosed pa t ien t s suf fe r ingfrom Major depression who practiced Sahajyoga medi ta t ion in add i t ion to theconvent iona l an t idepressan t t rea tment .

GROUP 2 (n=15) (9 Males and 6 Females)15 diagnosed patients suffering from Majordepress ion who rece ived convent iona lan t idepressan t t rea tment , bu t d id no tpract ice Sahaj Yoga meditat ion.

Sahaj yoga medi ta t ion

Saha j Yoga medi ta t ion was done forthi r ty minutes , three t imes per week for aperiod of eight weeks by all the subjects ofGroup 1. To ensure regularity and uniformityin Sahaj Yoga practice, the training of SahajYoga was g iven in the Depar tment o fPhysiology, Lady Hardinge Medical Collegeby Sahaj Yogi t ra ined in the a r t o f SahajYoga enunciated by H.H. Shri Mataji NirmalaDevi. The subjects practiced meditation in aqu ie t , we l l - i l lumina ted room s i t t ing in acomfortable posture. The technique used forSahaj Yoga was as described in the literature

(10) , (11) . A typ ica l sess ion cons i s ted ofques t ions and asse r t ions by the sub jec t .Thereaf te r , the sub jec t s p rac t iced s i l en tmeditat ion. If a thought came to the mind,they were ins t ruc ted to s imply wi tness i tbu t no t to f low deeper in to i t . Gradual ly ,with practice the subjects reported to be ina s ta te o f “ thought less awareness” . Saha jYoga was also practiced at bedtime by sittingin silent meditation with the feet dipped inwarm sa l ine water . Group 2 subjec ts wereprovided the same environment and attentionas Group 1 sub jec t s . However , ac tua lmedi ta t ion was no t p rac t iced by thesesub jec t s . The sub jec t s were ins t ruc ted tos imply p lace the i r hands a t d i f fe ren tpositions as during Sahaj Yoga practice andthereafter sit quietly with their eyes closed.

Written informed consent was taken fromal l the subjec ts . At the s ta r t o f the s tudy(Pre t es t va lue) , semi-s t ruc tured proformafor socio-demographic detai ls was f i l led inby a l l the sub jec t s . Al l the pa t ien t s werethen ra ted on Hami l ton Rat ing Sca le fo rDepress ion (HAM-D) . Subjec t s were thenassessed on Neuro-Cogni t ive Tes t Bat te ry .In the Neurocogni t ive Ba t te ry , the t es t swere p resen ted to a l l the sub jec t s in thesame order as has been ment ioned here :

• Le t te r Cance l la t ion tes t .

• Trail making Test ‘A’

• Trail making Test ‘B’

• Ruff Figural Fluency Test .

• Digi t Span Forward and Reverse Test .

The en t i re assessment took about 2–3hours . Also, the subjects were not a l lowed


more than two breaks in the ent ire sessionif so desired.

Al l the above tes t s were aga inadministered after two months of Sahaj Yogamedi ta t ion prac t ice (Pos t t es t va lue a t 8weeks). The data was recorded and analyzedsta t is t ica l ly .

Ins truments o f the s tudy

• Diagnos t ic and S ta t i s t i ca l Manual o fMental Disorders (DSM-IV) (12).

It is the official psychiatric coding systemused in the United States of America and itprovides specified diagnostic criteria providedfor each menta l d i sorder . These c r i t e r iainc lude a l i s t o f fea tures tha t mus t bepresent for a d iagnosis to be made. Thesecriteria increase the reliability of clinicians’process o f d iagnos i s . I t was due to th i sreason of h igh spec i f ic i ty tha t th i sinstrument was used to confirm the diagnosisof major depression in this study.

• Hami l ton Rat ing Sca le for Depress ion(HAM-D) (13).

This scale consists of 17 variables withratings from 0 to 4 for certain variables suchas depressed mood, guilt, suicidal tendencies,work and interests whilst other variables likeinsomnia , ag i ta t ion , and genera l somat icsymptoms a re ra ted f rom 0 to 2 . Theindividual scores for each variable are to beadded to provide for a cumulative score forthe pa t ien t . I t i s used for quant i fy ing theresults of an interview Reliability is good toexcellent, including internal consistency andin te r - ra te r assessments . Va l id i ty appears

good on cor re la t ion wi th o ther symptommeasures. Thus, it was included in this studyto ra te the depress ive component in thepa t ien t s suf fe r ing f rom major depress ived isorder .

• Neurocogni t ive Tes t Bat tery :

In o rder to fac i l i t a te rep l ica t ion , on lytes t s ava i lab le and f requent ly documentedin the neuropsycholog ica l l i t e ra tu re wereemployed (14).

! Let ter Cancel lat ion Test :

This t es t assesses v i sua l scanning ,response speed and sustained attention. Thesubject is presented with let ters of Englisha lphabe t , and i s ins t ruc ted to cance l ou tspecific letters. The score is the time takenby sub jec t to ac tua l ly per form th i s t ask .In addition, the numbers of different errors(omiss ions and commiss ions) done by thesubject are a lso counted.

! Trai l Making Test :

Part A : assesses visuomotor speed andattention. The subject is instructed to drawa s t ra igh t l ine to connec t 25 consecu t ivecircles. The score is the t ime taken by thesubject to complete the task.

Part B : In addition to visuomotor speedand attention, it requires the patient to shifts t ra tegy and hence , i s a sens i t ive measureof execu t ive func t ion as wel l . In th i s thesubject is instructed to connect 25 numberedand le t tered c i rc les by a l ternat ing betweenthe two sequences. The score is the total timetaken by the pat ient to complete the task.


! Ruff Figural Fluency Test :

This tes t permi t s us to s tudy the non-verba l f luency of a sub jec t , which i s anindirect measure of subject’s ability to forma s t ra tegy to comple te a g iven task . Thesubject i s presented wi th a sheet of paperon which 40 boxes are present. The objectiveis to draw dissimilar patterns in these boxesby joining dots present in these boxes in aspecified period of time. The score is basedon total number of dissimilar pat terns, andnumber o f persevera t ions . The ro ta t ionswere a l so no ted in th i s t es t a long wi thPatterns and Perseverations as Rotations areconsidered to be the hallmark in the strategicapproach (A measure of executive function).

! Digit Span :

Dig i t s Forward : assesses immedia teverba l memory span . In the t es t , sub jec t smus t repea t back sequences o f d ig i t s o fincreasing length read out by the examiner.The score is maximum number of digits thatthe pat ient can recal l .

Digits Backward : In addition to auditorya t ten t ion and shor t - te rm re tent ive capaci tyth i s t es t a l so assesses the ab i l i ty tomanipu la te in format ion in the verba lwork ing memory (and hence i s sens i t ivemeasure of executive function). The subjecthas to repeat the sequences of numbers ofincreas ing d ig i t length in reverse order towhat was said by the examiner. The score isthe maximum number of such digits that thepat ient is able to reverse .

Stat i s t i ca l ana lys i s

For each group , Mean and S tandardDevia t ion of the scores were ca lcu la ted .

In te r -group means d i f fe rences in Hamil tonRat ing Sca le fo r Depress ion & neuro-cogni t ive t es t pa rameters were t es ted fo rsignificance by using Students’ ‘t’ test. Forint ra-group comparisons of neuro-cogni t ivetest parameters, Wilcoxon Signed Rank testwas used . Chi - square t es t was used tocompare the sex-d i s t r ibu t ion , modi f iedKuppuswami socio-economic scale and drugregimes. The interpretation of ‘P’ values wasas follows :

P>0.05 - not significant. P<0.05 - Significant.P<0 .01 - Highly s ign i f ican t . P< .001 - Veryhighly signif icant .

RESULTS

The sub jec t s ’ charac te r i s t i cs and the i rrelevant clinical data are shown in Table I.Table I demonst ra tes tha t pa t ien ts in bothGroup 1 and Group 2 had no s ta t i s t i ca l lys ign i f ican t d i f fe rences in the age and sexdistribution. Revised Kuppuswami’s scale was

TABLE I : Showing sub jec t s ’ cha rac te r i s t i c s andc l in ica l da ta .

Parameters Group 1 Group 2(n=15) (n=15)

Age (yrs) (Mean±S.D.) 31.87±8.78 31.67±8.46G e n d e r• Females 5 6• Males 10 9Socio-economic status• Upper 0 0• Middle (upper & lower) 12 11• Lower 3 4Drug Regimen• T.C.A. 9 8• S.S.R.I. 6 7HAM-D (Mean±S.D.) 21.27±4.35 19.47±3.98

T.C.A. : Tri Cyclic Anti-depressants.S.S.R.R.I. : Selective Serotonin Reuptake Inhibitors.


used for determining socio-economic s tatusof the two groups. Both the groups had themajor i ty o f pa t ien t s f rom middle soc io-economic group and no significant differencewas found in socio-economic s ta tus of thetwo groups. Table I also shows no significantd i f fe rences in the number o f pa t ien t srece iv ing an t i -depressan ts (T .C.A. ’s andS.S.R.I . ’s) . Also, there were no s ignif icantd i f fe rences in base- l ine (Pre - tes t ) HAM-Dscores in the patients of Group 1 and Group2. So, the two Groups were comparable forthe study. Table II demonstrates percentagereduction in HAM-D scores at 8 weeks wassignificantly more in Group 1 patients thanin Group 2 patients (P=0.003). Also, there ismore s ign i f ican t change in number o fOmiss ions and Le t te r cance l la t ion t ime inGroup 1 sub jec t as compared to Group 2subjects. Significant improvement is seen inTrai l making Test ‘A’ & Trai l making test‘B’ in both the groups with no inter-groupdifferences. No significant change is seen inRuff f igural f luency test and Forward digitspan test in both the groups while there iss ign i f ican t improvement in Reverse d ig i tspan test in only Group 1 subjects with nochange seen in Group 2 subjects .

DISCUSSION

In the p resen t s tudy , two groups werewel l matched for age , sex, socio-economics ta tus and drug reg ime and there was nosignificant difference in the base l ine (Pre-tes t ) HAM-D Scores and neuro-cogni t iveprofile of the patients of two groups. So, thetwo groups were comparable for the study.

Execut ive func t ions a re per formed byPre- f ron ta l ne tworks which inc lude dorso-la te ra l p re f ron ta l , media l p re f ron ta l andorb i to f ron ta l components and the sub-

TABLE I I : Showing changes in HAM-D scores andNeuro-cogn i t ive t e s t pa ramete r s f rompre - t es t to pos t - t e s t in Group 1 andGroup 2 sub jec t s . (Mean±S.D. )

Parameters Group 1 Group 2(n=15) (n=15)

! HAM-D" P r e 21.27 ± 4.32*** 19.47 ± 3.98***" Pos t 8.27 ± 4.37 11.53 ± 4.26% Change –60.85 ± 4.97 –42.01 ± 2.81**

! Letter cancellationt e s t

• Time (sec)" P r e 147.73 ± 29.27** 152.6 ± 35.36*" Pos t 133.67 ± 32.59 137.8 ± 32.81

• Omissions" P r e 8.33 ± 5.29** 7.93 ± 5.31*" Pos t 5.73 ± 4.95 5.93 ± 3.59

• Commissions" P r e 0.13 ± 0.35 0.4 ± 1.06" Pos t 0 ± 0 0.13 ± 0.35

! Trail makingtest ‘A’ (sec)

" P r e 116.8 ± 44.91* 120.07 ± 39.82*" Pos t 108.4 ± 40.79 113 ± 34.35

! Trail makingtest ‘B’ (sec)

" P r e 200.6 ± 53.94** 188.13 ± 55.59**" Pos t 169.2 ± 53.92 166.2 ± 55.74

! Ruff figuralfluency test

" P r e 12.93 ± 8.51 11.6 ± 8.49" Pos t 13 ± 6.36 12.53 ± 8.39

• Rotat ions" P r e 3.33 ± 2.85 2.6 ± 2.67" Pos t 3.4 ± 2.69 2.8 ± 2.11

• Persevera t ion" P r e 23.73 ± 10.42 26 ± 9.82" Pos t 23.6 ± 8.38 24.67 ± 9.8

! Forward digitspan test

" P r e 4.67 ± 0.82 4.93 ± 0.96" Pos t 4.87 ± 1.13 4.8 ± 0.86

! Reverse digitspan test

" P r e 3.2 ± 0.68* 3.27 ± 0.88" Pos t 3.47 ± 0.64 3.47 ± 1.19

Wilcoxon Signed Ranked Test (Pre vs Post). Post HocComparison : Group 1 vs Group 2 - Non significant.


s t ruc tures wi th which they a re in te r -connected ( i .e . head of caudate and dorso-media l nuc leus o f tha lamus) (15) . Dorso-lateral prefrontal cortex (dlpfc) and anteriorcingulate cortex plays a uniquely critical rolein orchestrat ing working memory, a t tent ionand attentional set-shifting strategies (16, 17).

Prev ious s tud ies have shown tha tdepress ion a f fec t s the acquis i t ion ,memor iza t ion , and re t r i eva l o f e f for t fu lin format ion bu t spares au tomat ic l ea rn ing(18, 19) which demonstrates that execut ivefunc t ions and a t ten t iona l mechanisms a reselectively affected by depression (20). Thisi s cons is ten t wi th the assoc ia t ion be tweendepress ive mood and ac t iv i ty in theprefronta l and c ingula te cor t ices in neuro-imaging s tud ies (21 , 16) . Neuro- imagingstudies have implicated left dlpfc and orbito-f ron to-ven t ra l reg ion as major s i t es o ffunc t iona l and s t ruc tura l abnormal i t i es inmajor depress ion wi th marked decrease inneuronal and gl ial densi ty in these regions(22) . So , the re i s a conc lus ive sc ien t i f i cevidence to demonstra te the impairment offrontost r ia ta l c i rcui t ry (Prefrontal network)in the pat ients of Major depression due towhich they lack in their abil i ty to performthe neuro-cogni t ive t es t s o f a t t en t ion andexecut ive func t ions when compared wi thheal thy control subjects .

After 8 weeks of intervention (post test),there was significant reduction in the scoreson Hami l ton Rat ing Sca les for Depress ionin bo th Group 1 (Ant idepressan ts andSaha j Yoga) (P<0 .001) and Group 2 (onAnt idepressants only) (P<0.001) . However ,percentage reduction in HAM-D scores at 8weeks was s ign i f ican t ly more in Group 1patients than in Group 2 patients (P=0.003).These f ind ings demons t ra te the add i t iona l

antidepressant effects of Sahaj Yoga in themanagement of patients of Major depression.The importance of these f indings has beendiscussed in details in our previous study (23).

Also, after 8 weeks of intervention, therewas s ign i f ican t decrease in number o fomiss ions in bo th Group 1 and Group 2pa t ien t s in the Le t te r Cance l la t ion Tes t ,however , change was s ignif icant ly more inGroup 1 (P=0.002) as compared to Group 2pa t ien t s (P=0 .03) . S imi la r ly , more markedimprovement was seen in Letter cancellationt ime in Group 1 (P=0.006) as compared toGroup 2 pa t ien t s (P=0 .01) . There wassignificant improvement in Trail making test‘A’ in both Group 1 (P=0.019) and Group 2(P=0.017) patients with not much differencein be tween the g roups . S ign i f ican timprovement was also seen in Trail makingtest ‘B’ in both Group 1 (P=0.002) and Group2 (P=0.002) patients with not much differencein be tween the groups . In Ruf f F igura lFluency tes t and Forward Digi t Span tes t ,no s ign i f ican t improvement was seen ine i ther o f the g roups . However , the re wass ign i f ican t improvement in Reverse Dig i tSpan Test only in Group 1 patients (P=0.04)with no change seen in Group 2 patients .

So, our f indings demonstra te that thereis significant improvement in many cognitivedomains of attention and executive functionsin Group 2 pa t ien t s , which can on ly bea t t r ibu ted to the e f fec t o f convent iona lantidepressant medication. Many authors (24,25) have also reported this improvement insome neuro-cognitive functions with recoveryof mood. They have repor ted tha t manycogni t ive def ic i t s , bu t no t a l l r emi t uponrecovery . Remi t tance f rom cogni t iveimpairment in depressives is vitally important,as i t is l ikely to be a key factor affect ing


their abili ty to function occupationally andhence, the timing of their return to work (17).

Our f ind ings a l so show tha t Saha jYoga practice by Group 1 patients leads toadded improvement in a t t en t ion span ,concentration, visuo-motor speed in Group 1subjects and there was improvement in theexecu t ive func t ion ing of verba l work ingmemory , aud i to ry a t t en t ion & shor t - t e rmretentive capacity in only Group 1 patients.These findings demonstrate further cognitiveenhancement e f fec t in Group 1 depress ivesubjects (Antidepressants and Sahaj Yoga) onfew more executive functions in depressivepa t ien t s when compared wi th Group 2subjects (on Antidepressants only) and theseadditional beneficial effects can be attributedto the Saha j Yoga medi ta t ion prac t ice byGroup 1 subjects.

So, our study shows that al though anti-depressan ts cause improvement in manycognitive domains of attention and executivefunctions in patients of major depression andremain the main-s tay of t rea tment fo r thedepressive patients, Sahaj Yoga practice bydepressive patients can play adjunctive rolea long wi th convent iona l an t i -depressan ttreatment in causing cognit ive enhancementin a few additional executive functions andhence , in management o f depress ivedisorders. Sahaj Yoga meditation practice bydepress ive pa t ien t s can he lp in be t te rfunctioning and earlier rehabilitation of thesepa t ien t s . Our s tudy i s in agreement wi threcen t s tud ies conduc ted on SudarshanKr iya Yoga which have demons t ra ted i t se f f icacy in the management o f dys thymia ,

melancholia and depression (26, 27).

The mechanism by which Saha j Yogahe lps in the management o f depress ioncannot be deciphered from the present study.Accord ing to Saha j Yoga l i t e ra tu re ,ac tua l iza t ion of Kunda l in i awakening (bySaha j Yoga) t akes p lace in the L imbicsystem, giving rise to bliss, deep relaxationand v ibra tory awareness o f coo l b reezeflowing from the palms and top of the head.I t i s wel l known tha t l imbic sys tem hashypothalamus as i t s major substa t ion (28) .Probably , Kunda l in i awakening condi t ionsthe l imbic sys tem which modula tes theactivity of hypathalamic-hypophyseal-adrenalaxis. This brings about a better neuroeffectorcommunication thereby, affecting expressionof neuro t rophic fac tors , modula t ing theneuro t ransmi t te r s l ike se ro ton in , norep inephr ine and br ing ing about animprovement in different cognit ive domainsin pat ients of depression.

In the present study, it was not possibleto at tempt double bl ind condi t ions. Ethicalcons t ra in t s a l so l imi ted the use of a drugfree group or placebo group. Therefore, theresults can be considered to be preliminaryand be viewed with caution of potential raterb ias . However , no s ign i f ican t c l in ica ls ide e f fec t s (confus ion , CVS acc iden ts ,hypomaniac switch etc.) occurred with Sahajyoga practice in the study. Further researchis indicated for longer period and on largersample size to define the relative place forSahaj Yoga in the c l in ica l management ofdepress ive d i sorders . Compara t ive s tud ieswith other forms of Yoga are also required.

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