Mindfulness

Abstract & Commentary

Mindfulness in Disadvantaged Populations

By Ellen Feldman, MD

Altru Health System, Grand Forks, ND

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SYNOPSIS: Participation in mindfulness-based group therapy shows promise for reducing stress and improving functioning in this pilot study involving 27 socioeconomically disadvantaged African-American women.

SOURCE: Burnett-Zeigler I, Satyshur MD, Hong S, et al. Acceptability of a mindfulness intervention for depressive symptoms among African-American women in a community health center: A qualitative study. Complement Ther Med 2019;45:19-24.

Mindfulness, or the ability to stay grounded and focused in the present moment, non-judgmentally with curiosity and compassion, may feel like part of a modern-day trend, but actually it stems from ancient Buddhist meditation techniques.¹ In the 1970s Herbert Benson, MD, and Jon Kabat- Zinn, PhD, introduced a secularized form of mindfulness to the medical world as a way to combat stress and stress-related disorders, including depression.^1-3

Since that time, the popularity of mindfulness-based interventions has grown, with systematic studies looking at its usefulness in alleviating a variety of disorders, including depression. Mindfulness-based stress reduction (MBSR)⁴ and mindfulness-based cognitive therapy (MBCT)⁵ are two structured programs with evidence of efficacy in preventing depression relapse and in reducing depressive symptoms.

However, much of the supporting evidence comes from studies where participant homogeneity interferes with the generalization of findings. Specifically, a 2018 systematic review of 69 randomized controlled trials investigating MBSR and MBCT found only one of the studies deliberately recruited participants from racial minorities or who were of low socioeconomic status. In the 56 studies (out of the 69 total) reporting race, more than 79% of the participants identified as Caucasian, and the majority of the total participants reported income more than $40,000 yearly.⁶

However, poverty is a risk factor for depression, and studies in the United States have concluded that adult racial minorities are less likely than age-matched non-minority peers to receive treatment for mental health concerns. This high-risk population could clearly benefit from additional treatment options for depression. One concern in the literature about introducing mindfulness interventions to racial/ethnic minorities is that there could be a perceived conflict with religious or spiritual beliefs. Studies looking at this aspect of mindfulness have not found evidence of such a barrier.⁷

Recognizing the potential for use of such interventions in economically disadvantaged minorities, as well as the lack of studies involving this population, Burnett-Zeigler et al designed a pilot study to recruit socioeconomically disadvantaged women with depressive symptoms and determine if mindfulness-based exercises were acceptable and useful for this group. To this end, they recruited women aged 18-65 years from an urban community health center for the study.

Eligibility criteria included depressive symptoms in the mild-severe range (as measured by the Inventory of Depressive Symptomatology and the Quick Inventory of Depressive Symptomatology) without suicidal ideation, plan, or recent attempt. Exclusions included patients not fluent in English or patients currently practicing meditation or yoga at least weekly.

Notably, 86 women were referred (self-referred or from primary care) to this study — 55 were screened, and of the 50 eligible women, 31 enrolled in the study. There were two eight-week groups, each held for 90 minutes/week. The mean session attendance rate was 6.4 sessions for the 14 members of the first group and 6.6 sessions for the 15 members of the second group. The group intervention was an adaptation of classic MBSR with formal mindfulness training, including yoga and meditation instruction, weekly didactics, and assignments to practice daily and document between sessions.

In 2016, Burnett-Zeigler et al reported results from this study. Depression, perceived stress, and mindfulness practice at baseline, eight weeks (end of group), and 16 weeks were among the measurable outcomes. Quantitative results indicated a significant decrease in depression scores between baseline and 12 weeks (P = 0.04), with most of the drop occurring after week 8. Perceived stress scores fell throughout, with a significant drop (P = 0.02) between baseline and week 16. Other outcome measures, including mindfulness, self-acceptance, and growth, showed significant increases during the eight weeks and less significant increases at 16 weeks.⁸ In contrast, this follow-up study evaluates qualitative changes as documented by an analysis of a 60-minute focus group discussion after the eight weeks of mindfulness groups.

The aim of the study was to understand participants’ thoughts and attitudes toward the mindfulness intervention, including whether participants found the intervention useful, and to elicit feedback regarding barriers to participation. Focus group invitations were issued to women who had attended at least one of the eight mindfulness groups; a small financial incentive (transportation reimbursement and a $25 gift card) were offered to enhance motivation for attendance.

The summarized results include:

1. Reasons for joining the study included motivation to learn yoga, learn how to reduce stress, and revive or relearn mind-body approaches used in the past (such as meditation).
2. Perceived benefits of the mindfulness groups fell into four general areas as defined by the women in the focus group: anger control, emotional control, awareness/focus, and relaxation. Women voiced specific statements regarding improvement in at least one of these areas.
3. Perceived barriers to attendance, as defined by women in the focus group, fell into four general areas: transportation, time conflict with work, time conflict with family responsibilities, and psychological. Some of the psychological barriers included stigma and avoidance of difficult emotions.
4. “Facilitators” to attendance included holding the groups at a familiar site (medical clinic), providing transportation cards, homework, and the reinforcement of concepts with compact discs, social support, and keeping the group as women only.
5. Suggestions included offering a more advanced group after completion of the first group, expanding time for yoga, increased time for mindfulness meditation practice in groups, and offering the groups to other populations, such as teens in the community.

Commentary

At first glance, this qualitative analysis may not appear impressive. The numbers of participants are low, and specific data points (such as percentage of women reporting specific improvements) are lacking. A deeper look, however, reveals that Burnett-Zeigler et al accomplished a stated goal of understanding perceived benefits, usefulness, and barriers to a mindfulness intervention in this population in a straightforward manner — by asking the women and then analyzing the replies.

The low number of participants is very appropriate for a pilot study. More studies looking at the use of mindfulness techniques and interventions in low socioeconomic populations and in racial minorities will promote understanding whether the acceptability and usefulness of this type of intervention are generalizable, or whether it is more suited to specific subsectors. Cost factors, not reported in this investigation, also will be useful in evaluating the full benefits of mindfulness interventions.

This work also may serve as a reminder to primary care physicians that antidepressants are not the only intervention with evidence-based efficacy for depression and depressive symptoms. Depression is a complex, multifactorial disease state best addressed with a holistic, multipronged approach.⁹

Although this study focused on qualitative results, some of the numbers deserve mention. Out of the 55 women screened to participate in this study, 50 (91%) were eligible. This highlights the level of depression in this population and suggests motivation to explore complementary therapy or a perception of unmet need in current treatment plans. This is consistent with reports in the literature noting that compliance with antidepressants is low (40% to 75%) in general, and that African-Americans and Hispanics are more likely than Caucasians to find antidepressants unacceptable because of a variety of concerns, including side effects and addiction.⁹ Availability of alternative interventions may help increase willingness to be treated. However, it also is noteworthy that, of the 50 eligible participants, only 31 (62%) enrolled in the study. Understanding the factors compelling these women not to proceed would be helpful in gaining a more complete picture.

It is both curious and troubling that past studies of mindfulness-based interventions have not targeted lower socioeconomic groups or racial/ethnic minorities. This qualitative analysis of the Burnett-Zeigler et al pilot study, along with the previously published quantitative results, point strongly to a prominent role for mindfulness interventions in the treatment of depression for disadvantaged, depressed women, and may spark curiosity about evidence-based studies in other marginalized communities.

While waiting for broader and more definitive studies, it is well worth promoting and advocating for the availability of this intervention when working with depressed women in urban clinic settings.

REFERENCES

1. Buchholz L. Exploring the promise of mindfulness as medicine. JAMA 2015;314:1327-1329.
2. Kabat-Zinn J. Coming to Our Senses: Healing Ourselves and the World through Mindfulness. Hachette; 2005.
3. Benson-Henry Institute. Dr. Herbert Benson. https://bensonhenryinstitute.org/about-us-dr-herbert-benson/
4. Kuyken W, Warren FC, Taylor RS, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials. JAMA Psychiatry 2016;73:565-574.
5. MacKenzie MB, Abbott KA, Kocovski NL. Mindfulness-based cognitive therapy in patients with depression: Current perspectives. Neuropsychiatr Dis Treat 2018;14:1599-1605.
6. Waldron EM, Hong S, Moskowitz JT, Burnett-Zeigler I. A systematic review of the demographic characteristics of participants in US-based randomized controlled trials of mindfulness-based interventions. Mindfulness 2018;9:1671-1692.
7. Chin G, Anyanso V, Greeson J. Addressing diversity in mindfulness research on health: A narrative review using the addressing framework. Cooper Rowan Med J 2019;1:2.
8. Burnett-Zeigler IE, Satyshur MD, Hong S, et al. Mindfulness based stress reduction adapted for depressed disadvantaged women in an urban federally qualified health center. Complement Ther Clin Pract 2016;25:59-67.
9. Gelenberg AJ, Freeman MP, Markowitz JC, et al. Practice guideline for the treatment of patients with major depressive disorder. 3rd edition. American Psychiatric Association. Published October 2010. https://www.umhealthpartners.com/wp-content/uploads/2016/10/DepressionAPA.pdf