Essentials of Complementary and Alternative Medicine (June 1999)

Central Nervous System
Extensive research has explored electroencephalogram (EEG) changes during meditation. Most of this work shows increases in high-voltage theta wave burst activity 
and frontal alpha wave coherence in tracings obtained during meditation. EEG phase coherence, a measure of simultaneous phase EEG activity at different cortical 
locations, is also increased during meditation and may be associated with some of the subjective experiences of meditation (
27
); however, the significance of these 
changes is unknown. Functional brain scanning, a newer technique that directly measures brain activity or central nervous system blood flow, has been used to 
quantify changes in regional brain function during meditation. Meaningful changes in the activation of focal brain regions have been documented during meditation 
(
37
, 
38
). Research into the physiology of perception in meditators has also found changes in sensitivity to stimuli and in sensory evoked potentials (
39
, 
40
 and 
41
).
Autonomic Nervous System
It has been difficult to demonstrate a consistent effect from meditation on autonomic nervous system function. There is little evidence for a reproducible effect on heart 
rate that differs significantly from other types of rest. However, galvanic skin resistance seems to increase reliably during meditation, suggesting decreased 
sympathetic activity (
26
). A recent preliminary study found that meditators experienced no changes in circulating catecholamines but did experience significant 
decreases in beta-adrenergic receptors (
42
). Another study found decreases in autonomic activation among inexperienced meditators but increased activation in more 
proficient meditators (
43
). This disparity possibly explains some of the inconsistent results in other studies.
Clinical Research
Research on meditation as a medical therapy has been complicated by some of the same problems confronting research of other alternative and complementary 
therapies: although the prospective, randomized, placebo-controlled double-blind study is the gold standard of clinical research, it may not be optimal for the 
investigation of meditation and similar mind–body therapies. It is difficult to create a suitable placebo for a meditation-based intervention, especially when a research 
design requires using a blinded control group that cannot be told if it is receiving the active treatment. It is difficult to design a convincing placebo that can be 
presented as meditation. An interesting study that investigated biofeedback and cognitive therapy for vascular headache prescribed “pseudomeditation” as a placebo 
control and found that this placebo became an active relaxation condition that provided a significant therapeutic benefit (
44
).
It can be argued that meditation works by the same mechanism as does the placebo effect. This point does not diminish the effect of meditation, but rather suggests 
that treatments that enhance the mind's capacity to heal the body (with low cost and little risk) may provide meaningful clinical benefits. A placebo may be an effective 
treatment because it provides a focus through which the mind can affect the body; meditation may provide or heighten the same benefit.
Even if a suitable placebo can be devised, it may be difficult to randomize participants to a nontreatment group. Individuals who will commit the time and effort to 
practice meditation regularly are usually convinced of its benefits and may not consent to be part of an untreated control group. The cultivation of a regular meditation 
practice demands more active participation from the patient than do most medical treatments. Some studies compare meditators to a demographically similar 
nonmeditating control population; but even when this is done prospectively, significant differences in lifestyle or personality between two such groups are likely. These 
differences weaken the findings of any such comparison.
USE OF THE SYSTEM FOR TREATMENT
Major Indications
P
AIN

Despite the inherent challenges of designing conclusive clinical studies of meditation, there is a considerable amount of evidence that details the medical benefits of 
meditation practice. In general, meditation practice decreases the number of physical symptoms reported by patients with a wide variety of medical conditions (
Fig. 
30.1
). Meditation is a generally accepted therapy for chronic pain (
45
, 
46
). A recent Technology Assessment Statement of the National Institutes of Health reviewed 
the evidence for the use of different relaxation treatments for chronic pain, including meditation, autogenic training, and progressive muscle relaxation. The statement 
concluded that, “The evidence is strong for the effectiveness of this class of techniques in reducing chronic pain in a variety of medical conditions” (
47
).
F
IGURE
 30.1. Change in medical symptoms following completion of a hospital-based meditation program. (Adapted with permission from Kabat-Zinn J. Mindfulness 
meditation. In: Haruki Y, Ishii Y, Suzuki M, eds. Comparative and psychological study on meditation. The Netherlands: Eburon, 1996:161–170.)
P
SYCHOTHERAPY
Meditation has long been used as a psychological therapy, and some of the earliest proponents of meditation in the West were psychologists. During a lecture at 
Harvard University in the early 1900s, the renowned psychologist William James is said to have recognized a visiting Buddhist monk in the audience and exclaimed, 
“Take my chair! You are better equipped to lecture on psychology than I. This is the psychology everyone will be studying twenty-five years from now” (
48
). Although 
his prediction was premature, in the last 20 years many clinicians have reviewed the use of meditation as an adjunct to psychotherapy and explored its 
psychotherapeutic benefits (
49
, 
50
, 
51
, 
52
, 
53
, 
54
, 
55
, 
56
, 
57
 and 
58
). A recent book by Epstein explores the uses of mindfulness meditation in psychotherapy. He 
examines meditation from the perspective of Western psychology and claims that “the meditative practices of bare attention, concentration, mindfulness, and analytic 
inquiry speak to issues that are at the forefront of contemporary psychodynamic concern; they are not about seeking some otherworldly abode .... I hope to make 
clear how potent a force they can be in conjunction with more traditional Western psychotherapies” (
59
).
Other researchers have noted that Eastern psychology provides a fresh perspective on the nature of mind and its workings. At a symposium sponsored by Harvard 
Medical School, Daniel Goleman remarked:
Buddhist psychology offers modern psychology the opportunity for genuine dialogue with a system of thought that has evolved outside of conceptual 
systems that have spawned contemporary psychology. Here is a fully realized psychology that offers the chance for a complementary view of many of the 
fundamental issues of modern psychology: the nature of mind; the limits of human potential for growth; the possibilities for mental health; the means for 
psychological change and transformation (
60
).
Clinical research into the psychotherapeutic benefits of meditation clearly suggests that regular meditation results in decreased anxiety (
61
, 
62
, 
63
, 
64
, 
65
 and 
66
) 
and depression (
66
, 
67
 and 
68
) (
Fig. 30.2
).
F
IGURE
 30.2. Measures of psychological distress before and after completion of a hospital-based meditation program. (Adapted with permission from Kabat-Zinn J. 
Mindfulness meditation. In: Haruki Y, Ishii Y, Suzuki M, eds. Comparative and psychological study on meditation. The Netherlands: Eburon, 1996:161–170.)
The insight resulting from mindfulness meditation is similar to what is described during cognitive therapy, in which patients are taught to objectively see their thoughts 
and feelings to learn where cognitive and emotional distortions arise (
69
). Some therapists have suggested that the antidepressant effects of cognitive therapy can be 
maintained with meditation (
70
). Meditation also has similarities to the process of psychodynamic psychotherapy (
71
).
H
YPERTENSION AND
 C
ARDIOVASCULAR
 D
ISEASE
Meditation has long been recommended as an effective treatment for hypertension, but controversy exists over the magnitude of the benefit it provides. Some studies 
have documented only small decreases in blood pressure as compared with medication (
72
, 
73
 and 
74
). Much of the published research has inadequate study design 
and sample size. One recent review identified more than 800 published studies and concluded that only 26 were well-designed enough to be useful (
72
). Despite 
these methodological problems, most of the studies show reductions in blood pressure with meditation (
75
, 
76
). Antihypertensive drugs are clearly more effective than 
meditation, but because of the high prevalence of hypertension, even a relatively small treatment benefit could be expected to have a meaningful impact on both 
public health and the overall cost of medical care. Meditation is likely to be a highly cost-effective and efficacious treatment of mild hypertension when the risks and 
cost of pharmacological treatment outweigh the benefits. It might also be a useful adjunct to drug treatment.
Meditation, in conjunction with standard medical care, has been used to treat coronary artery disease. One recent study documented a significant decrease in 
exercise-induced cardiac ischemia measured with standard treadmill exercise testing (
Fig. 30.3
) (
77
). Dean Ornish and his group at the University of California have 
demonstrated significant regression of coronary artery stenoses as measured by both coronary angiography and positron emission tomography with a lifestyle 
regimen that included at least 1 hour of stress management, including meditation, daily (
78
, 
79
 and 
80
). Preliminary findings suggest that cardiovascular mortality in 
the elderly is also decreased by meditation (
81
). Accumulating data about the psychosocial factors associated with coronary heart disease have fueled interest in this 
area (
82
). Many studies are ongoing, and much can be learned regarding the role of meditation and other mind–body interventions in the treatment of heart disease 
during the next decade.

F
IGURE
 30.3. Exercise duration, workload, and time of onset of ST segment changes after 6 to 8 months of meditation. (Adapted with permission from Zamarra JW, 
Schneider RH, Besseghini I, et al. Usefulness of the transcendental meditation program in the treatment of patients with coronary artery disease. Am J Cardiol 
1996;77:867–870.)
O
THER
 I
NDICATIONS
Meditation has been studied as a treatment for many other diseases, but in most areas the studies are too small or too few to allow meaningful conclusions. 
Numerous case reports have documented regression of various cancers with intensive meditation, but there are no well-designed prospective clinical trials. An 
investigation of the use of meditation for the treatment of breast cancer is currently underway at the University of Massachusetts (Kabat-Zinn J, personal 
communication). A small prospective study used stress-management techniques that included meditation for a group of HIV-positive men, and improvements were 
found in T-cell counts as well as in several psychological measures of well-being (
83
). One study found that meditation decreased the symptoms of fibromyalgia, a 
difficult-to-treat syndrome of chronic pain and fatigue, and reported significant improvement in over one-half of participants (
84
).
Meditation has been reported to improve function or reduce symptoms in patients with several neurological diseases, including epilepsy in patients resistant to 
standard treatment (
85
, 
86
) as well as patients with Parkinsonism (
87
) and patients with multiple sclerosis who experience fatigue (
88
).
Adverse Effects
A few reports describing deleterious psychological effects of meditation have been published. There is no prospective study of the adverse effects of meditation, 
although in the face of the millions of individuals who practice meditation regularly, such problems seem uncommon. Individuals with severe preexisting 
psychopathology, such as schizophrenia, are probably at the highest risk of experiencing adverse effects; one report suggests that meditation precipitated acute 
psychotic breaks in patients with chronic schizophrenia (
89
). Episodes of depersonalization are also reported, although they may not create any problems for the 
individual; it is difficult to interpret them outside of the context of the individual's experience (
90
, 
91
).
Shapiro canvassed 27 participants of an intensive meditation retreat and found that, although subjects reported many more beneficial than negative effects, 63% of 
them had experienced at least one adverse effect at some time. Adverse effects were described as including “increased awareness of negative qualities and emotions 
within myself”; increased disorientation, “such as becoming aware of how low my self image is, how often I get down on myself”; addiction to meditation; and boredom 
or pain. The same study found that 92% of the subjects reported positive effects, including “greater happiness and joy; more positive thinking; more self confidence; 
better ability to get things done; better problem solving ... more relaxed; less stressed” (
92
). Finally, one researcher reported an increased incidence of what were 
described as “complex partial epileptic-like signs” in regular meditators, although symptoms included “profound meaning from reading poetry/prose” and “religious 
phenomenology” (
93
). Thus, it is plausible that individuals predisposed to such experiences are more likely to pursue meditation in the first place. In general, most 
proponents of meditation in a medical setting would not recommend meditation to individuals with severe personality disorders, psychotic disorders, or severe 
depression (especially with suicidal ideation or intent) unless concomitant psychotherapeutic or medical treatment is obtained.
ORGANIZATION
Training and Credentialing
One of the challenges caused by the more widespread use of meditation in health care is the lack of formal credentialing or licensure for meditation instructors. There 
are many traditions of meditation, and individuals with widely varying degrees of training and experience teach meditation in many different contexts. Although this 
means that there are numerous opportunities to learn how to meditate, there is no consensus about what constitutes the necessary training for a meditation teacher. 
There is no certification for Western instructors who wish to teach meditation as a medical or mind–body therapy. Traditional religions or organizations, such as 
Buddhism or TM, that include meditation as a core component of their activity have specific requirements for formal training and explicit credentialing for new 
teachers. Usually, extensive experience and a high level of expertise are required for authorization as a teacher within such traditions, but such teachers may not 
have extensive experience with medical patients.
At the University of Pennsylvania Program for Stress Management, we suggest that an individual have at least 10 years of personal practice and formal instruction in 
mindfulness meditation before receiving additional training to teach meditation. For individuals with appropriate training, we have offered a 4- to 6-month internship 
that addresses some of the specific issues which arise when meditation is practiced as a medical therapy. Our teachers are also expected to spend at least 2 weeks 
out of each year in intensive meditation retreats. There are exceptions to these guidelines, but we encourage individuals with less experience to work wholeheartedly 
to deepen their own practice and study.
The Stress Reduction Clinic at the University of Massachusetts also provides several types of professional training programs. Five- to seven-day residential programs 
are offered at sites throughout the United States. These programs are highly experiential and require no previous training or experience. Further study is also 
available at a Professional Internship Program held at its Massachusetts clinic. These programs are not intended to certify that a participant is qualified to teach 
meditation. They provide basic training in the practice and principles of mindfulness meditation and explore how it might be applied to an individual's own personal or 
professional situation. Jon Kabat-Zinn's book  Full Catastrophe Living details the University of Massachusetts program and is an excellent introduction to the use of 
mindfulness meditation in medicine.
Reimbursement
Because meditation is not considered to be a medical procedure or intervention by most insurers, it is often not reimbursed by medical insurance. Providers of medical 
or psychological treatment can teach patients about meditation as part of a routine patient encounter and then bill for the service provided. Many patients simply opt to 
pay for additional meditation training themselves. Various groups are engaged in ongoing discussions with third-party payers and HMOs, and these groups expect 
increasing numbers of insurers to pay for meditation as a medical treatment for selected patients. Ongoing research documenting the benefits of meditation will 
encourage this trend.
PROSPECTS FOR THE FUTURE
The presentation of meditation has evolved to meet the needs of each culture it has entered. Meditation is entering Western medicine as a secular and scientifically 
validated medical therapy. In keeping with the inclinations and goals of Western culture, meditation will be used because of its practical and concrete benefits. 
Meditation will likely be shown to be an efficacious treatment for many medical problems and an effective way to decrease health care costs and utilization. Ultimately, 
however, meditation will be practiced here for the same reason that it has flourished in so many cultures for thousands of years—because it helps people to feel better 
and to enjoy life more fully.

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1993;76:80–82.

Appendix A. Organizations and Suggested Readings
Essentials of Complementary and Alternative Medicine