Translational Research and Evidence-Based Practice
Management of anxiety and mood disorders can be managed through psycho-pharmacotherapy, psychotherapy, or both. Posttraumatic stress disorder is an illness that follows traumatic events or experiences. PTSD presents with both anxiety and mood symptoms. The goals of management of PTSD include the reduction of symptoms and prevention of future occurrences to improve quality of life.
Medications such as antidepressants have been used in the symptomatic control of symptoms of PTSD. Mindfulness-based stress reduction (MBSR) strategies have been valuable in managing stress and mood-related illness in mental health. The use of MBSR strategies, especially meditation has been applied in counseling and therapy to improve patient outcomes.
My evidence-based practice (EBP) project aimed at examining the usefulness of meditation in the management of PTSD symptoms to improve the quality of life of trauma victims. This paper aims to explain the literature acquisition strategies used, synthesize the outcomes of literature appraisal, and recommend best practices from these outcomes.
Literature Search Strategies
The process of literature search started with the development of a research question. The research question adopted a PICOT format. My PICOT question stated: Among Veterans in a primary psychiatric setting, does the translation of Davis, L et al. on Meditation-Based Stress Reduction intervention impact Post-Traumatic Stress Disorder (PTSD) symptoms as measured by the Davidson trauma scale compared to current practice in eight weeks?
The population in this clinical inquiry were veterans in the psychiatric primary care setting. This population was selected because of their vulnerability to outcomes of trauma, such as acute stress disorder and post-traumatic stress disorder. Experiences in combat can be traumatic, and effects can be witnessed later after the service in the military. The intervention, MBSR, focuses on stress management, and stress is the major acute reaction in PTSD.
Therefore, focusing on the major symptoms can be fruitful in therapy. This project adopted the framework in the work of Davis, L et al., a randomized control trial that used MBSR as the intervention. The outcomes of intervention would be reflected in the occurrence of PTSD symptoms. To objectively quantify these symptoms, the Davidson trauma scale would be used eight weeks before and after the study project period.
The second step in the EBP acquisition of literature was the identification of sources of literature. Five literature sources were identified. These sources were databases and included Medline, EBSCO, ProQuest Central, Cochrane, and Elsevier databases. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, Cochrane database for systematic reviews (CDSR), and Science Direct were used to access these databases. These databases provided various kinds of articles, some as full text and others as abstracts.
The third step of literature acquisition was a literature search. A literature search was done using search key terms, Boolean operators, and search filters. Search keywords were Meditation-Based Stress Reduction, MBSR, meditation, veterans, PTSD, PTSD symptoms, posttraumatic stress disorder, PTSD management, current practice, psychotherapy, and medication therapy. Boolean operators, ‘AND’ and ‘OR,’ were used to further limit the search and obtain more relevant search results.
Search filters used limited search results to research articles only, peer-reviewed sources published within the past ten years, published in English and available as full texts, and articles from medical and mental health fields. The search results from each database were manually handpicked based on their relevance to the clinical inquiry.
Priorities were given to articles from more recent studies conducted in the United States, Canada, the United Kingdom, Australia, China, and other European countries. The handpicked results were then compared for duplicate results and the availability of full texts. Articles selected for appraisal and evidence synthesis were also prioritized based on their research designs, as primary and pure quantitative sources were selected first.
Primary Quantitative Research
The article by Gallegos et al. (2020) was a quantitative study that adopted a two-arm, randomized pilot clinical trial design. This study compared the outcomes of MBSR intervention and health education manual for control among trauma-exposed individuals. MBSR intervention was found to reduce PTSD symptoms such as emotional dysregulation, physiological stress, and attentional function. However, this reduction was not statistically significant. High attrition rates were a key limitation of this study. This article supports the use of my intervention in reducing symptoms of psychological and physiological diseases.
A quantitative study with prospective cohort design and RCT design by Harding et al. (2018) evaluated outcomes of MBSR among 55 veterans who had PTSD and irritable bowel syndrome (IBS) for stress symptoms and mindfulness skill building. In their study, Harding et al. (2018) found that statistically significant reduction in PTSD symptoms but a non-significant reduction in IBS symptoms among these patients.
The severity of symptoms also reduced for both disorders and after 4 months of study, only 77.5% could meet the diagnosis of PTSD. This article extends the use of my intervention to other causes of stress and anxiety, such as irritable bowel syndrome.
Davis et al. (2019) conducted a quantitative method study that adopted a multisite, single-blind, randomized control trial design. This study compared rates of remission of symptoms for intervention groups that received MBSR and control groups that received present-centered group therapy (PCGT). The difference in the rates of remission, 30.7% and 27.3% for MBST and PCGT, respectively, were not statistically significant even though MBSR recorded higher rates. This study could not thus ascertain the superiority of MBSR. This article compared my intervention to another non-trauma-focused intervention, PCGT.
Simshäuser et al. (2020) researched the effect sizes and feasibility of MBSR among 214 migraine patients through a quantitative study that adopted a randomized clinical trial design. The participants were sourced from internet platforms. The control group who received psychoeducation and active muscle relaxation strategies recorded a lower reduction in their anxiety which was statistically significant. However, the difference in their lower scores in mindfulness and depression was not statistically significant. The superiority of MBSR in enhancing adaptation and coping still requires further research. This article assessed my intervention’s use of a rare delivery mode, the internet.
A randomized controlled trial by Dumarkaite et al. (2022) examined the effects of online MBSR intervention on posttraumatic stress disorder and complex posttraumatic stress disorder symptoms among 53 young individuals in Lithuania who had past traumatic encounters and trauma-related symptoms. PTSD symptoms, CPTSD symptoms, negative feelings of self-concept, and self-organization disturbances between intervention and control groups who received no MBSR were assessed in this study.
MBSR lowered PTSD symptoms and distances in self-organization more significantly than scores reported in the control groups. The difference in other measures was not statistically significant. Notably, higher attrition rates were recorded in the intervention than in the control groups. This article assessed the use of my intervention in a younger population, thus suggesting its feasibility of use in different populations and age groups.
Primary and Secondary Sources
A systematic review by (Hilton et al., 2017) compared MBSR to treatment as usual (TAU) intervention among patients with post-traumatic stress. This high-level evidence study that involved a meta-analysis of 10 RCTs found that other comparators, such as yoga and the Mantram repetition program, were not superior to MBSR in PTSD symptom reduction. Some studies did not include blinding, thus a risk of bias that affected the quality of the evidence in this study. This article examined my intervention in different primary sources and compared it with more than one other related non-pharmacological interventions.
Lang et al. (2012) reviewed various meditative processes with the potential for improving PTSD symptoms. This study systematically searched and synthesized the literature on mindfulness, Mantram, and compassion meditation strategies. This review study concluded that meditation holds promise for use among PTSD patients to reduce symptoms. However, this study acknowledged the limitation in literature evidence for meditation use on PTSD, thus the need for further research. This study reviewed the key theme in my intervention, mindfulness, in different modes of delivering stress reduction strategies.
A randomized pilot trial by Juul et al. (2020) compared a mindfulness-based stress reduction course, a locally-developed stress reduction intervention, and a waiting list control group in a real-life municipal healthcare setting. This study randomized 71 adults from the Municipality of Aarhus in Denmark who had contacted the health center with stress-related complaints into MBSR (24), LSR (23), and the waiting list group (24).
The key findings were that MBSR outcomes were significantly improved for PTSD symptoms. However, there was no blinding, thus the risk of experimenter bias. This study assessed the feasibility of modifying my key interventions to focus on the target population’s needs.
Hou et al., 2019) investigated and compared the impact of mindfulness meditation training offered via two delivery systems, in-person (IP) and online via Virtual World (VW), with a waitlist control group. Despite the IP group recording lower scores than the other two groups, there were no statistically significant differences in training scores. This study involved both active-duty army officers and veteran volunteers. This could have resulted in the high attrition in this study which took more than two months. My intervention in this article is compared to delivery modes, such as in-person and over the internet. These are possible avenues to deliver my intervention and reach various populations.
Nidich et al. (2018) randomized 203 veterans with a current diagnosis of PTSD into two intervention groups that received Transcendental Meditation (TM) and prolonged exposure therapy (PE) and a control group that received PTSD health education (HE). This study found that TM resulted in significantly lower CAPS scores than PE. However, TM remains viable in PTSD symptom reduction. TM was non-trauma-focused as opposed to PE. This article compared my intervention to another non-trauma-focused intervention.
Bormann et al. (2018) conducted an RCT that randomized 173 veterans with PTSD into an intervention group that received a Mantram repetition practice (MNP) intervention and a control group that received present-centered therapy (PCT). MNP was more effective in reducing the severity of PTSD symptoms than PCT despite statistically non-significant differences in CAPS scores between these groups after 2 months of follow-up. Both MNP and PCT are non-trauma-focused strategies for PTSD symptoms. This article also compared my intervention to another non-trauma-focused intervention.
A pilot randomized controlled trial by Bellehsen et al. (2022) involved Transcendental Meditation as an intervention and treatment as usual (TAU) as a control intervention for 40 veterans with PTSD. After 12 weeks, there were statistically significant differences in reduction in CAPS scores between the TM group (higher decrease) and TAU groups (lower = decrease).
The difference in the decrease in anger and increase in quality of life between the two groups was not statistically significant. Significant reductions were also realized in TM groups than in TAU groups for self-report measures of PTSD symptoms, depression, anxiety, and sleep difficulties. This article emphasized the benefits of my intervention not only in PTSD symptoms improvement but also in sleep and depression.
Herron & Rees (2018) conducted an uncontrolled pilot study that offered 89 veterans with PTSD Transcendental Meditation (TM) techniques for their symptoms. After one month of TM practice, this one-group pretest-posttest design study reported a 52.5 to 22.5 decline in median PTSD scores, a 51.52 to 23.43 decline in mean PTSD scores, and 87% of veterans reported a decline in PSTD symptoms. Therefore, these findings suggested a cause-effect relationship. Lack of controls in the study limited comparison and assessment of significance. This article supports the use of my intervention MBSR designing program to reduce PTSD symptoms in populations.
Marchand et al. (2019) conducted a chart review design study in a Veterans Administration Medical Center (VAMC) involving records of ninety-eight veterans with psychiatric illness who had been enrolled in mindfulness-based cognitive therapy (MBCT) in four years and attended an average of 4.8 sessions out of 8. A significant reduction in psychiatric admissions from pre to post was recorded in this study. However, high attritions were also recorded during this period. This article supports my intervention’s use in reducing admissions and improving symptoms.
Comparison of Articles
The reviewed 15 articles share various similarities but also differ in many different ways majority of the article is primary studies that used the RCT designs. In these primary studies, the interventions in mindfulness-based stress reduction are offered in different techniques, settings, or propulsion. The commonest population that received this intervention were veterans with PTSD.
However, other outcomes, such as IBS, physiological stress, and migraines, are studied in different primary articles. Delivery of MBSR in person and over the internet has been studied in these articles, but in-person delivery is becoming commoner. Most primary quantitative studies reviewed used PTSD cores to objectively compare the outcomes of the intervention’s use.
Most of the studies supported the superiority of MBSR over other interventions including treatment as usual (TAU). Only one study compared prolonged exposure therapy. Prolonged exposure therapy is one of the commonly used psychotherapeutic modalities in the reduction of PTSD symptoms. However, this method is trauma-focused and thus may be uncomfortable for some PTSD patients.
My intervention focused on meditation as part of mindfulness-based strategies. However, one study included in this review focused on mindfulness-based cognitive therapy. Therefore, this source provided a different way to look at the alternatives to my intervention. One common limitation was reported in almost all primary sources that were reviewed. High attrition was associated with the use of my intervention. Some studies reported that longer follow-up periods contributed to this attrition. Secondary sources emphasize the need for further research to complement existing evidence. The risk of bias from primary sources was also a limitation of the findings of secondary sources.
Recommendations for Future Research
One common outcome that was glaring from this review was the limitation in data and the low quality of evidence reviewed. Most studies used had relatively smaller sample sizes, and some lacked blinding. Therefore, implementation of their findings risks the poor quality of outcomes due to a lack of generalizability and biased findings. High attrition rates made comparison less reliable.
Therefore, gaps still exist in the effectiveness of this intervention in larger populations. Most studies analyzed this intervention as a separate intervention. Its value, in addition to treatment as usual interventions, was not assessed. This gap still undermines its value owing to the various effectiveness recorded in current therapies.
The outcomes of using my intervention as an add-on therapy could be synergistic or additive. Therefore, future research should assess this intervention as additional therapy to current therapies and pharmacotherapies. Posttraumatic stress disorder has a myriad of symptoms and stress is one of them. My intervention focuses on stress reduction and thus might not be effective for patients with other symptoms not necessarily a result of stress, such as intrusive thoughts, emotional detachments, and loss of interest. This emphasizes the need for future research to evaluate the value MBSR could add to PTSD patients if these symptoms are present.
The development of shorter mindfulness-based stress reduction strategy interventions can be explored in fruitier studies to reduce the high attrition rates reported in previous studies. Coupling mindfulness-based intervention with pleasurable activities can reduce the risk of attrition among participants in the intervention groups (Marchand et al., 2019). However, the risk of these pleasurable activities acting as confounders in the analysis of the outcomes is unknown.
Of the reviewed studies, very few studies did not include veterans. Sources of trauma are valued; regardless of the kind of trauma, PTSD can present in varying severities. Therefore, future studies should also include other populations, such as victims of sexual violence, road traffic accidents, and intimate partner violence. My review only included one level I evidence source. This source included a meta-analysis of 10 RCTs (Melnyk & Fineout-Overholt, 2018). Therefore, there is still a paucity of high-level evidence that should be looked into in future studies
MBSR for stress reduction has the potential for application to many ‘stressful’ conditions, such as PTSD. My PICOT question guided a literature search using keywords, Boolean operators, and search filters from five databases to acquire 15 primary and secondary sources. These sources focused on MBSR use in PTSD and related condition that have PTSD-related symptoms.
Most of the included studies were primary sources that were RCTs. In these studies, the efficacies of MBSR was compared with other related intervention, both trauma-focused and non-trauma-focused. MBSR emerged more efficacious than these other interventions apart from prolonged exposure therapy that was reported in one primary study. High attrition rates and quality of evidence were key limitations in most studies reviewed.
Most studies studied MBSR as a standalone strategy. However, its value can be beyond. Therefore, future studies should assess the value of MBSR strategies as add-on therapies to usual care strategies and other non-trauma-focused interventions such as PCGT and Mantram repetition practices.
Bellehsen, M., Stoycheva, V., Cohen, B. H., & Nidich, S. (2022). A pilot randomized controlled trial of Transcendental Meditation as a treatment for posttraumatic stress disorder in veterans. Journal of Traumatic Stress, 35(1), 22–31. https://doi.org/10.1002/jts.22665
Bormann, J. E., Thorp, S. R., Smith, E., Glickman, M., Beck, D., Plumb, D., Zhao, S., Ackland, P. E., Rodgers, C. S., Heppner, P., Herz, L. R., & Elwy, A. R. (2018). Individual treatment of posttraumatic stress disorder using mantram repetition: A randomized clinical trial. The American Journal of Psychiatry, 175(10), 979–988. https://doi.org/10.1176/appi.ajp.2018.17060611
Davis, L. L., Whetsell, C., Hamner, M. B., Carmody, J., Rothbaum, B. O., Allen, R. S., Al Bartolucci, A. B. P. P., Southwick, S. M., & Bremner, J. D. (2019). A multisite randomized controlled trial of mindfulness-based stress reduction in the treatment of posttraumatic stress disorder. Psychiatric Research and Clinical Practice, 1(2), 39–48. https://doi.org/10.1176/appi.prcp.20180002
Dumarkaite, A., Truskauskaite-Kuneviciene, I., Andersson, G., & Kazlauskas, E. (2022). The effects of an online mindfulness-based intervention on posttraumatic stress disorder and complex posttraumatic stress disorder symptoms: A randomized controlled trial with 3-month follow-up. Frontiers in Psychiatry, 13, 799259. https://doi.org/10.3389/fpsyt.2022.799259
Gallegos, A. M., Heffner, K. L., Cerulli, C., Luck, P., McGuinness, S., & Pigeon, W. R. (2020). Effects of mindfulness training on posttraumatic stress symptoms from a community-based pilot clinical trial among survivors of intimate partner violence. Psychological Trauma: Theory, Research, Practice and Policy, 12(8), 859–868. https://doi.org/10.1037/tra0000975
Harding, K., Simpson, T., & Kearney, D. J. (2018). Reduced symptoms of post-traumatic stress disorder and irritable bowel syndrome following mindfulness-based stress reduction among veterans. Journal of Alternative and Complementary Medicine (New York, N.Y.), 24(12), 1159–1165. https://doi.org/10.1089/acm.2018.0135
Herron, R. E., & Rees, B. (2018). The transcendental meditation program’s impact on the symptoms of post-traumatic stress disorder of veterans: An uncontrolled pilot study. Military Medicine, 183(1–2), e144–e150. https://doi.org/10.1093/milmed/usx059
Hilton, L., Maher, A. R., Colaiaco, B., Apaydin, E., Sorbero, M. E., Booth, M., Shanman, R. M., & Hempel, S. (2017). Meditation for posttraumatic stress: Systematic review and meta-analysis. Psychological Trauma: Theory, Research, Practice and Policy, 9(4), 453–460. https://doi.org/10.1037/tra0000180
Hou, Y., Zhao, X., Lu, M., Lei, X., Wu, Q., & Wang, X. (2019). Brief, one-on-one, telephone-adapted mindfulness-based stress reduction for patients undergoing percutaneous coronary intervention: a randomized controlled trial. Translational Behavioral Medicine, 9(6), 1216–1223. https://doi.org/10.1093/tbm/ibz130
Juul, L., Pallesen, K. J., Bjerggaard, M., Nielsen, C., & Fjorback, L. O. (2020). A pilot randomized trial comparing a mindfulness-based stress reduction course, a locally-developed stress reduction intervention, and a waiting list control group in a real-life municipal health care setting. BMC Public Health, 20(1), 409. https://doi.org/10.1186/s12889-020-08470-6
Lang, A. J., Strauss, J. L., Bomyea, J., Bormann, J. E., Hickman, S. D., Good, R. C., & Essex, M. (2012). The theoretical and empirical basis for meditation as an intervention for PTSD. Behavior Modification, 36(6), 759–786. https://doi.org/10.1177/0145445512441200
Marchand, W. R., Yabko, B., Herrmann, T., Curtis, H., & Lackner, R. (2019). Treatment engagement and outcomes of mindfulness-based cognitive therapy for veterans with psychiatric disorders. Journal of Alternative and Complementary Medicine (New York, N.Y.), 25(9), 902–909. https://doi.org/10.1089/acm.2018.0511
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Lippincott Williams and Wilkins.
Nidich, S., Mills, P. J., Rainforth, M., Heppner, P., Schneider, R. H., Rosenthal, N. E., Salerno, J., Gaylord-King, C., & Rutledge, T. (2018). Non-trauma-focused meditation versus exposure therapy in veterans with post-traumatic stress disorder: a randomized controlled trial. The Lancet. Psychiatry, 5(12), 975–986. https://doi.org/10.1016/S2215-0366(18)30384-5
Simshäuser, K., Lüking, M., Kaube, H., Schultz, C., & Schmidt, S. (2020). Is mindfulness-based stress reduction a promising and feasible intervention for patients suffering from migraine? A randomized controlled pilot trial. Complementary Medicine Research, 27(1), 19–30. https://doi.org/10.1159/000501425