Ann. N.Y. Acad. Sci.

ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Issue: Meditation

Mindfulness meditation and the immune system: a

systematic review of randomized controlled trials
David S. Black1 and George M. Slavich2
1
Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.
2
Cousins Center for Psychoneuroimmunology and Department of Psychiatry and Biobehavioral Sciences, University of
California, Los Angeles, California

Address for correspondence: David S. Black, Ph.D., M.P.H., Department of Preventive Medicine, Keck School of Medicine,
University of Southern California, 2001 N. Soto Street, Suite 302D, Los Angeles, CA 90032. davidbla@[Link]

Mindfulness meditation represents a mental training framework for cultivating the state of mindful awareness
in daily life. Recently, there has been a surge of interest in how mindfulness meditation improves human health
and well-being. Although studies have shown that mindfulness meditation can improve self-reported measures of
disease symptomatology, the effect that mindfulness meditation has on biological mechanisms underlying human
aging and disease is less clear. To address this issue, we conducted the first comprehensive review of randomized
controlled trials examining the effects of mindfulness meditation on immune system parameters, with a specific
focus on five outcomes: (1) circulating and stimulated inflammatory proteins, (2) cellular transcription factors and
gene expression, (3) immune cell count, (4) immune cell aging, and (5) antibody response. This analysis revealed
substantial heterogeneity across studies with respect to patient population, study design, and assay procedures.
The findings suggest possible effects of mindfulness meditation on specific markers of inflammation, cell-mediated
immunity, and biological aging, but these results are tentative and require further replication. On the basis of this
analysis, we describe the limitations of existing work and suggest possible avenues for future research. Mindfulness
meditation may be salutogenic for immune system dynamics, but additional work is needed to examine these effects.

Keywords: mindfulness; meditation; intervention; immune system; inflammation; biology; cytokines; aging; health;
disease

Introduction mindfulness-based intervention (MBI). These pro-

grams are based on secularized teachings from var-
Mindfulness is an intrinsic and modifiable capac-
ious historical mindfulness meditation traditions,
ity of the human mind. As a state and process of
especially Eastern humanistic contemplative tradi-
consciousness, it is most commonly defined as “the
tions rooted in the cultivation of personal insight
awareness that emerges through paying attention
and wisdom.2,3 To reduce symbolic dissonance and
on purpose, in the present moment, and nonjudg-
surmount cultural barriers to access and participa-
mentally to the unfolding of experience moment
tion, MBIs serve as a template for translating ancient
by moment” (p. 145).1 Mindfulness meditation, in
teachings into a language and practice that is accept-
turn, represents a systematic framework and process
able and easily understood by contemporary society.
for cultivating mindfulness in daily life by inten-
The presence of MBIs in major healthcare
tional and sustained practice.
settings is at an all-time high. Indeed, almost
Several standardized programs have been devel-
80% of the 140 accredited medical schools or
oped for cultivating mindfulness meditation, with
their associated universities in the United States
the goal of realizing its potential benefits for human
presently incorporate MBIs into their treatment,
health and well-being. Credit is ordinarily assigned
education, and/or research programs.4 Reviews of
to the 1970s Mindfulness-Based Stress Reduc-
randomized controlled trials (RCTs) have shown
tion (MBSR) program as the first standardized

doi: 10.1111/nyas.12998
Ann. N.Y. Acad. Sci. xxxx (2016) 1–12 
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Mindfulness meditation and the immune system Black & Slavich

that MBIs can exert some beneficial effects on review. We then discuss the findings and highlight
stress-related ailments, psychiatric disorders, and lingering issues and possible avenues for future
disease symptomatology.5–9 However, mindfulness research in order to help advance the goal of better
meditation is not regarded as a therapeutic panacea understanding how mindfulness meditation may
for all ailments, and the effects of MBIs on health shape biological aging and disease.
appear similar in magnitude to those demonstrated
by other conventional approaches for treating stress, Literature review methods and findings
pain, and illness, including the administration of We scanned all potentially relevant articles pub-
psychoactive medications, psychotherapy, health lished between January 1966 and July 2015 to
education, and behavior modification.6,10–15 MBIs examine the literature on mindfulness meditation
nevertheless enjoy increasing appeal, stemming and immune system activity. The year 1966 was
from a mix of promising empirical evidence, selected as a start date because this was when the
a modern medicine paradigm that increasingly first empirical paper on mindfulness meditation
emphasizes the role of patients as active and appeared. The terms immune, inflammation,
accountable participants in health care (e.g., cytokine, proinflammatory, biomarker, blood, saliva,
self-management of disease and engagement in urine, telomere, and infection were used to search
preventive behaviors),16–18 and a growing emphasis the American Mindfulness Research Association’s
on transtherapeutic interventions.19 publication database ([Link]), which
So far, the research base documenting the archives over 4000 published journal articles,
effectiveness of MBIs relies heavily on participants’ pulling from comprehensive monthly literature
self-reports of their own health status, which searches of PubMed, Ovid, PsycINFO, Web of
can be prone to bias.2,8,10,20 A more recent, yet Science, and Google Scholar. Citations were also
relatively small, literature also exists examining received from researchers in the field, and table-of-
how MBIs affect objective biological markers of content searches were conducted for topic-specific
human health,21 but to date, no comprehensive journals. In addition to the computer-assisted
literature reviews have been conducted to evaluate searches, bibliographies of previous publications on
how mindfulness meditation influences biological the topic were screened for relevant articles. When
processes that are most centrally involved in disease required, authors were contacted to clarify details
pathogenesis. Markers of immune system activity regarding their study methods or blood sampling
are particularly relevant in this context, given that protocols. Articles were included if they (1) used
immune system dynamics have been implicated in an RCT design, (2) administered mindfulness
several major mental and physical health problems, meditation as the main intervention element, (3)
including asthma, rheumatoid arthritis, metabolic objectively assessed a biomarker of immune-related
disorders, neurodegenerative disorders, certain activity, and (4) were published in English.
types of cancer, posttraumatic stress disorder, and
depression.22,23 Therefore, in the present review, Description of the field of work
we examined the question of whether MBIs can Included studies
influence peripheral biomarkers of immune system A total of 20 RCT studies met the inclusion criteria
activity. mentioned above and were thus included (Table 1).
To conduct this review, we performed a compre- Two studies resulted in multiple publications, but
hensive literature search that involved identifying these data were only counted once (Table 1; Study
all of the RCTs that tested the effects of mindful- column). The mean sample size of these 20 studies
ness meditation on immune system biomarkers. was n = 80 (range: 21–201), and a total of 1602
We focused specifically on five immune system participants were included in the analysis.
outcomes that are relevant for health, namely
(1) circulating and stimulated inflammatory Comparison conditions
proteins, (2) cellular transcription factors and gene Less than half of the studies (n = 8; 40%) admin-
expression, (3) immune cell count, (4) immune istered a comparison condition that accounted
cell aging, and (5) antibody response. Below, we for the nonspecific effects of the intervention
describe the methods and results of this systematic protocol, including time, attention, and group

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Black & Slavich Mindfulness meditation and the immune system

Table 1. Randomized controlled trials reporting the effects of mindfulness meditation on immune system parameters
Analysis Comparator/ Intervention Specimen Immune-related
Reference Main purpose of study sample (n) control group Participants description collection findings
Barrett Test effect of mindful 149 Moderate- Older community MBSR derived; 8 Nasal wash; blood >IL-8;
et al.24 meditation or exercise intensity adults; 82% weekly 2.5-h (serum, neutrophils;
Hayney on incidence, duration, exercisea ; female; ages group sessions PBMCs) with virus
et al.44 and severity of acute waiting list 59.3 ± 6.6 years influenza prevalence;
respiratory infection vaccine IgA, IgG;
illness IFN-␥ ;
IL-10
Black Test effect of mindful 49 Sleep hygiene Community MAPs; 6 weekly Blood (PBMCs) <NF-␬B (both
et al.12,75 meditation or sleep educationa adults; 67% 2-h group groups)
hygiene on sleep quality female; ages sessions
in older adults 66.3 ± 7.4 years
Bower et al.37 Test effect of mindful 71 Waiting list Breast cancer MAPs; 6 weekly Blood (PBMCs, <NF-␬B;
meditation on stress and patients; 100% 2-h group plasma) >IFN-1; <IL-6
depressive symptoms in female; ages sessions (dependent on
women diagnosed with 46.1 (± 28.4–60 practice
early stage breast cancer range) years dosage); CRP;
sTNF-RII
Carlson Test effect of mindful 88 Supportive- Breast cancer MBSR derived; 8 Blood (WBCs) >telomere length
et al.65 meditation or group expressive survivors; weekly 1.5-h (trend for
a
therapy/stress group therapy ; 100% female; group sessions attenuated
management on 1-day stress ages 54.4 ± + retreat decrease when
telomere length in management 9.0 years treatment
distressed breast cancer seminar groups
survivors combined vs.
seminar)
Creswell Test effect of mindful 48 1-day stress HIV-1+ MBSR; 8 weekly Blood (plasma) >CD4+ T
et al.59 meditation on CD4+ T education community 2-h group lymphocyte
lymphocyte declines in seminar adults; 9% sessions count (buffered
distressed HIV+ adults female; ages + retreat decline vs.
40.0 ± 9.0 years controls)
Creswell Test effect of mindful 40 Waiting list Lonely older MBSR; 8 weekly Blood (PBMCs, <NF-␬B; <CRP
et al.38 meditation on loneliness adults; 80% 2-h group plasma) (trend); IL-6
in older adults female; ages sessions
64.4 ± 6.0 years + retreat
Daubenmier Test effect of mindful 37 Waiting list Overweight/obese MBSR derived; 9 Blood (PBMCs) >Telomerase
et al.67 meditation on women; 100% weekly 2.5-h activity (trend
telomerase activity in female; ages not group sessions dependent on
overweight and obese indicated + retreat practice
women dosage)
Davidson Test effect of mindful 41 Waiting list Corporate MBSR; 8 weekly Blood (serum) >Influenza
et al.73 meditation on brain and employees; 2.5-h group with influenza antibodies
immune function 71% female; sessions + vaccine
ages 36.0 retreat
(± 23–56
range) years
Elsenbruch Test effect of mindful 30 Waiting list Ulcerative colitis MBSR + Blood (EDTA <TNF-␣ (trend)
et al.43 meditation + patients; 50% mind–body whole
multimodality program female; ages program; stimulated)
on neuroendocrine and 42.9 ± 8.6 years 10 weekly 6-h
immune measures in group sessions
patients with ulcerative
colitis
Fogarty Test effect of mindful 42 Waiting list Rheumatoid MBSR; 8 weekly Blood (serum) CRP
et al.46 meditation on disease arthritis group sessions;
activity in rheumatoid patients; 88% hours not
arthritis patients female; ages indicated
52.0 ± 12.0
years
Gonzalez- Test effect of mindful 35 Usual care HIV+ patients; MBCT; 8 weekly Blood (WBCs) >CD4+ T
Garcia meditation on quality of 49% female; 2.5-h group lymphocyte
et al.60 life, emotional status, ages 49.4 ± 5.2 sessions count (up
and immune status years 3 months)
among long-term HIV
patients

Continued

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Mindfulness meditation and the immune system Black & Slavich

Table 1. Continued
Analysis Comparator/ Intervention Specimen Immune-related
Reference Main purpose of study sample (n) control group Participants description collection findings
Jacobs et al.68 Test effect of meditation 46 Waiting list Meditation retreat Mindfulness, Blood (PBMCs) >Telomerase
practice on immune cell participants; compassion, activity
telomerase activity 53% female; and equanimity
ages 49.0 meditations;
(± 23–69 3-month group
range) years residential
retreat
Jedel et al.39 Test effect of mindful 53 Mind–body Ulcerative colitis MBSR; 8 weekly Blood (serum); <CRP (among
meditation on flare ups medicine patients in 2.5-h group stool non-flared);
and quality of life in coursea remission; 56% sessions IL-6; IL-8;
ulcerative colitis patients female; ages >IL-10 (among
46.0 ± 12.8 flared);
years calprotectin
Lengacher Test effect of mindful 82; 124, Waiting list Breast cancer MBSR-derived; 6 Blood (WBCs) >T cell activation;
et al.45,66 meditation on immune respec- patients; 100% weekly 2-h >IFN-␥ /IL-4
recovery following breast tively female; ages sessions ratio;
cancer recovery 58.0 ± 9.0 years >CD4+ /CD8+
ratio (trend);
CD3+ ,
CD4+ , CD8+ ;
NK cells; B
lymphocytes;
>telomerase
activity;
telomere
length
Malarkey et al.40 Test effect of mindful 170 Lifestyle University MBSR derived; 8 Blood (serum) <CRP (trend);
meditation on education faculty/staff weekly 1-h IL-6
inflammatory markers coursea with group sessions
in workers with cardiovascular + retreat
cardiovascular disease risk;
disease risk 88% female;
ages 51.0 (± 0.8
SE) years
Moynihan et al.72 Test effect of mindful 201 Waiting list Older adults; 62% MBSR; 8 weekly Blood (serum) >IgG (immediate
meditation on brain female; ages 2-h group with KLH post); <IgG
function and antibody 73.3 ± 6.7 years sessions + challenge (24 weeks)
response in older adults retreat
Oken et al.41 Test feasibility of 21 Dementia Community- MBCT-derived; 6 Blood (serum) TNF-␣; IL-6;
mindfulness meditation education dwelling weekly 1.5-h CRP
in a clinical trial design coursea ; respite caregivers; 76% group sessions
for a larger study among care female; ages
caregivers 62.5 ± 11.6
years
Rosenkranz Test effect of mindful 49 Health Community MBSR; 8 weekly Skin (blister fluid) <TNF-␣
et al.25 meditation on enhancement volunteers; 2.5-h group (dependent on
physiological stress and programa 80% female; sessions + practice
neurogenic ages 45.9 ± retreat dosage); IL-8
inflammation responses 10.9 years
SeyedAlinaghi Test effect of mindful 171 Education and HIV+ patients; MBSR; 8 weekly Blood (plasma) >CD4+ T
et al.61 meditation on CD4+ support 31% female; 2.5-h group lymphocyte
T lymphocyte count resources ages 35.1 ± 6.5 sessions count (up to
in HIV patients years 6 months)
Zautra et al.42 Test effect of mindful 137 Cognitive Rheumatoid MBSR/MBCT Blood (PBMCs IL-6
meditation or cognitive behavioral arthritis derived; 8 stimulated)
behavioral therapy on therapya ; diagnosed; 68% weekly 2-h
pain in patients with arthritis female; ages group sessions
rheumatoid arthritis education 57.3 ± 15.3
coursea years
a Condition is comparable based on nonspecific treatment factors, such as time, attention, and group support.
MBSR, mindfulness-based stress reduction; MAPs, mindful awareness practices; MBCT, mindfulness-based cognitive therapy;
PBMCs, peripheral blood mononuclear cells; WBCs, white blood cells; KLH, keyhole limpet hemocyanin; <, decrease; >, increase;
, null change; IL, interleukin; CRP, C-reactive protein; Ig, immunoglobulin; NF-␬B, nuclear factor-␬B; IFN, interferon; TNF, tumor
necrosis factor; sTNF-RII, soluble tumor necrosis factor receptor type II; Th, T helper; and NK, natural killer.

4 Ann. N.Y. Acad. Sci. xxxx (2016) 1–12 

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Black & Slavich Mindfulness meditation and the immune system

effects. Active comparator programs included exer- spanning 6–10 weeks. Eight of the studies (40%)
cise, sleep hygiene, group therapies, mind–body held an additional single-day intensive meditation
medicine, health education courses, and cognitive retreat per conventional MBSR administration. Par-
behavioral therapy. Half of the studies used a wait- ticipants in one study lived at the retreat location for
ing list or usual care group for comparison to mind- 3 months and practiced daily meditation.
fulness meditation (n = 10; 50%), which did not
account for nonspecific effects. Other nonequiv- Collection of biological specimens
alent comparator groups included less intensive Eighteen studies (90%) collected peripheral blood
single-day educational courses, access to resource via venipuncture for processing of the target blood
services, and short-term respite care for caregivers specimen or cell type. The most commonly reported
(n = 2; 10%). processing protocol was the extraction of periph-
eral blood mononuclear cells (PBMCs) using ficoll
Sample selection
for immune bioassay. This method is used to iso-
Females were oversampled, as 14 of the 20 stud-
late leukocytes (white blood cells consisting of T, B,
ies examined (70%) had samples that were 60%
and natural killer (NK) cells) from other more pre-
or more female. This is partly due to disease-
dominant immune cells (i.e., granulocytes, includ-
specific recruitment of breast cancer patients, but
ing neutrophils, eosinophils, and basophils). Nasal
may also indicate possible participation bias favor-
mucous was collected in one study using a nasal
ing females due to sex differences in motivation to
wash approach during participant acute respiratory
practice mindfulness meditation or participation in
infection episodes.24 Another study induced skin
research studies focused on health and wellness.
blisters using a vacuum-pressurized blister template
Supporting this last possibility, studies sampling
and subsequently collected blister fluid.25
the general community, university staff, and corpo-
rate employees also showed proportionately greater
Excluded studies
female participation. Ten studies (50%) selected
Six studies tested the effect of a mindfulness
samples on the basis of disease inclusion criteria
meditation intervention on at least one immune
(e.g., breast cancer, HIV positive, ulcerative colitis,
parameter,26–33 but were excluded because
and rheumatoid arthritis), and five studies (25%)
they lacked an RCT design. In brief, these quasi-
recruited participants on the basis of a proposed
experimental studies used nonrandomized matched
risk factor (e.g., aging, poor sleep, loneliness, over-
control and single-group cohort designs. The
weight/obesity, cardiovascular disease). Finally, five
median sample size of these six studies was n = 51
studies (25%) recruited healthy volunteers (e.g., cor-
(range: 34–66), with samples consisting of breast
porate employees, older adults, meditators, or com-
cancer and prostate cancer patients, experienced
munity residents).
meditators, HIV-diagnosed individuals, and
Intervention dosage women with a trauma history. Blood was collected
All but three studies included in this review admin- in five studies (83%), and saliva was collected in
istered an MBSR or MBSR-derived program (i.e., one study. All interventions were MBSR or MBSR-
MBSR with cognitive therapy or additional psy- derived programs. Significant changes in immune
choeducational content), indicating high similarity measures were observed for levels, count, activity,
in intervention type across studies. Of the remaining or expression of interleukins (IL)-4, IL-6, and IL-10;
interventions, two studies reported on the use of a interferon gamma (IFN-␥ ); NK cells; monocytes;
standardized Mindful Awareness Practices (MAPs) eosinophils; receptor-interacting serine–threonine
course, and one study broadly defined their pro- kinase (RIPK2); cyclooxygenase (COX2); regulated
gram as mindfulness, compassion, and equanim- upon activation normal T cell expressed and
ity meditations led by a senior meditation teacher. presumably secreted to stromal-derived factor ratio
Of note, MAPs and the generalized mindfulness (RANTES/SDF-1); and telomere length. Findings
program appeared to be conceptually the same as from these studies may suggest potential biomarker
MBSR and differed only in program dosage and targets for future investigation, but the results
degree of documented standardization. All classes are preliminary and should be interpreted with
were administered in weekly group-based sessions caution.

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Mindfulness meditation and the immune system Black & Slavich

Summary of evidence from randomized stimulated TNF-␣ production following MBSR

controlled trials intervention.43 Furthermore, three studies mea-
sured IFN,37,44,45 one of which showed a relative
Below, we report the results of our systematic review
increase in IFN-I in female breast cancer patients
of the 20 RCT studies that met all of the inclu-
after a 6-week MAPs intervention.37 A second study
sion criteria, organized by outcome. Table 1 pro-
showed that females recovering from breast cancer
vides descriptions and the results of the 20 studies
who received MBSR had an increased IFN-␥ /IL-4
included in this review.
ratio. Finally, six studies measured CRP,37–41,46 of
Circulating and stimulated inflammatory which three showed a reduction in CRP, with one
proteins study showing reduced CRP levels after MBSR
Inflammatory proteins are produced by immune among non-flared patients with ulcerative colitis,39
cells and serve as extracellular communicators dur- and two other studies showing a trend for reduced
ing immune system activity. When circulating, CRP levels after MBSR-type programs among non-
these proteins propagate proinflammatory (e.g., diseased samples displaying an inflammatory risk
liver-derived C-reactive protein; CRP) or anti- factor.38,40
inflammatory (e.g., cell-derived IL-10 cytokine)
effects. These proteins are essential for systemic Cellular transcription factors and gene
preservation (i.e., protection against autoimmu- expression
nity and septic shock) and immune cell differen- Transcription factors are intracellular molecules
tiation; however, dysregulated and chronically ele- that, in immune cells, modulate the activity of
vated levels of proinflammatory proteins increase immune response genes and their production
risk for disease, poor healing, and mortality.34–36 Of of extracellular proteins.47 For example, nuclear
the 20 studies reviewed, nine measured inflamma- factor-␬B (NF-␬B) is a transcription factor that,
tory cytokines, including IL-6, IL-8, IL-10, tumor when activated, translocates into the cell nucleus
necrosis factor (TNF)-␣ and its receptor agonist and binds to DNA at the promoter region, thus acti-
sTNF-RII, and IFN-I, as well as CRP. vating genes for expression.48 NF-␬B functions as a
Five studies quantified circulating levels,37–42 precursor to increased concentrations of proinflam-
and one additional study reported on stimulated matory cytokines in peripheral blood and thus helps
levels,42 of IL-6 in blood. Of these studies, one coordinate the inflammatory response.49,50 Some
study of female breast cancer patients engaging in psychoneuroimmunologic models propose that
a 6-week MAPs course (compared to a waiting-list NF-␬B activity is a key intracellular pathway linking
control group) showed a relative reduction in the central nervous system psychological threat
post-intervention circulating levels of IL-6 that was cascade with neuroendocrine signal–mediated
dependent on the frequency of practice dosage.37 peripheral immune system dysregulation.51,52
Three studies measured IL-8,24,25,39 one of which Consistent with these models, acute psychological
showed a relative increase in IL-8 in nasal secretions stress has been shown to activate NF-␬B in
in older community-dwelling adults after an 8-week PBMCs.53–55
MBSR course (compared to moderate-intensity Of the studies reviewed, three measured NF-␬B
exercise).24 In addition, two studies measured IL-10 in PBMCs37,38,56 and showed a reduction in NF-␬B
in blood,24,39 one of which showed a relative increase after the MBI. Two studies—one in lonely older
in IL-10 in ulcerative colitis patients after MBSR adults and the other in breast cancer patients—
(compared to a matched mind–body medicine pro- showed a relative reduction in the expression of
gram), specifically among patients who experienced NF-␬B after MBSR and MAPs (compared
a symptomatic flare up.39 Four studies measured to waiting-list controls) using promoter-based
TNF-␣,25,37,41,43 of which one study of healthy bioinformatics measures of functional genomic
community volunteers showed reductions in activity.37,38 A third study showed that MAPs pro-
TNF-␣ in blister fluid following MBSR, with these duced a reduction in activated NF-␬B p65 in
effects being dependent on practice time,25 and a older adults exhibiting sleep disturbances; however,
second study of ulcerative colitis patients showed NF-␬B was also significantly decreased in the highly
a trend effect for reductions in lipopolysaccharide- active sleep hygiene comparison condition.56

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Black & Slavich Mindfulness meditation and the immune system

Immune cell count quantified telomere length,65,66 one examining

When engaged by an immune challenge, immune breast cancer survivors showed a trend for the
cells are differentially activated, generated, and then MBSR-derived intervention to attenuate the telom-
deployed by the immune system to target regions ere shortening observed in the control group;65
to protect the body against infection and promote however, these effects were observed only when sam-
tissue recovery. As such, cell distribution or count ples from the mindfulness meditation and support-
is used as a diagnostic marker for various immune- ive group therapy groups were combined to increase
compromising diseases. For example, a decline in statistical power. Of the three studies that mea-
CD4+ T lymphocyte count is a standard immune sured telomerase activity, all showed an increase
cell signal of disease progression in HIV patients.57 in telomerase activity after mindfulness medita-
Further, chronic stress and depression can inhibit tion, at least at the trend level, among a diverse
immune cell activity and proliferation, and thus set of samples (e.g., meditation retreat partici-
weaken defenses against tumorigenic surveillance pants, overweight/obese women, and breast can-
and growth.58 cer patients).66–68 In one of these three studies, the
Immune cell counts pertain to cells constituting increase was dependent on program attendance—
the innate (neutrophils) and adaptive (T, B, and specifically, only high treatment-regiment adherers
NK cells) subsets, and these counts were quanti- showed a trend for mindfulness meditation–related
fied in five studies.24,45,59–61 In one of these stud- increases in telomerase activity.67
ies, there was no relative change in neutrophils
(mucous from nasal wash) after an MBSR-derived Antibody response
intervention in older adults experiencing an acute Antibodies are immunoglobulins (IgG, IgA, IgM,
respiratory illness.24 Of the other four studies that IgD, and IgE) or molecules secreted by immune
enumerated lymphocytes in blood, all identified cells (B lymphocytes) that identify and neutral-
either an increase or a buffered decline in T lym- ize pathogens (via antigen flagging). Antibodies
phocyte cell count (CD4+ T, CD4+ /CD8+ ratio, T constitute humoral immunity and help immune
helper (Th)1/Th2) and/or activation (% activated cells inactivate toxic substances, attack viruses
T cells) after mindfulness meditation in samples of and bacteria, and assist in the function of other
patients diagnosed with a disease (i.e., HIV or breast immune cells. Suboptimal antibody response is
cancer) as compared to controls.45,59,61,62 Three of commonly found in immune-compromised indi-
these studies were restricted to people diagnosed viduals (e.g., HIV disease progression),69 persons
with HIV.59,61,62 B lymphocyte and NK cell counts experiencing chronic stress,70 and older adults
did not show relative changes in a study of breast (>60 years of age).71 Antibody titer tests demon-
cancer patients after intervention.45 strate serologic immunity by quantifying the level
of antibodies in blood, mucous, or other tissue
Immune cell aging samples.
Immune cell telomeres are protective DNA and Antibodies were measured in three studies,44,72,73
protein complexes that function as caps to two of which examined antibody response
protect and stabilize the ends of eukaryotic chromo- to influenza vaccination;44,73 one revealed that
somes, which truncate during cell division.63 Short- MBSR led to a significantly greater rise in
ened telomeres are a marker of immune cell aging hemagglutination-inhibition influenza antibody
and vulnerability to apoptosis, and are associated titers from the 4- to 8-week blood draw period
with poorer clinical outcomes and premature death (compared with controls in a sample of corpo-
in various age-related diseases.64 Telomere length is rate employees).73 The second study did not show
protected in part by the naturally occurring enzyme relative changes in serum influenza antibody or
telomerase, which helps slow or reverse cell aging.63 nasal IgA in older adults.44 The antigen keyhole
Longer telomeres and higher telomerase activity are limpet hemocyanin was administered in a third
thus considered to be salutogenic immune system study of older adults, which showed a relatively
profiles. greater increase in IgG immediately after MBSR
Four studies measured telomere length and/or intervention; additionally, a smaller increase in IgG
telomerase activity.65–68 Of the two studies that was observed at the 24-week assessment.72

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Mindfulness meditation and the immune system Black & Slavich

Figure 1. Mindfulness meditation and immune system biomarkers. This systematic review of 20 randomized controlled trials,
comprising more than 1600 participants, revealed replicated, yet tentative, evidence that mindfulness meditation is associated with
changes in select immune system processes involved in inflammation, immunity, and biological aging. NF-␬B, nuclear factor-␬B;
CRP, C-reactive protein.

Summary of evidence and implications for if robust and maintained over time, these
future research types of shifts in immune system activity could
potentially have beneficial effects on health by influ-
The present review is the first to interrogate the
encing mechanisms that are known to affect biolog-
findings of the RCTs that have been conducted to
ical aging and disease. For example, countering a
date on mindfulness meditation and the immune
dysregulated or hypersensitive immune system pro-
system. This comprehensive examination included
file with mindfulness meditation could theoretically
data from 1602 participants and revealed tentative
function to improve organism fitness by enhancing
evidence that mindfulness meditation is associated
immune defenses that protect against viral and bac-
with changes in select biomarkers of immune sys-
terial infection, as well as various age-related dis-
tem activity. When using the criteria of three or
ease conditions, including cardiovascular disease,
more RCTs showing that mindfulness meditation
osteoporosis, arthritis, type 2 diabetes, frailty, and
has at least a trend-level or dosage-dependent effect
some cancers. To test this possibility, future studies
on immune parameters, we identified mindfulness
will need to examine associations between mind-
meditation-related effects for the following four
fulness meditation, immune function, and disease
parameters: reductions in the activity of the cellular
symptomatology.
transcription factor NF-␬B, reductions in circulat-
Insights garnered from this review provide the
ing levels of CRP, increases in CD4+ T cell count
basis for further theory building and empirical
(in HIV-diagnosed individuals), and increases in
investigation into if, and if so, how, mindfulness
telomerase activity (Fig. 1). In contrast, null find-
meditation influences biological processes involved
ings or a lack of replicated effects were found for
in aging and disease. For example, these findings
antibodies (IgA, IgG, influenza), interleukins (IL-
extend existing models of mindfulness meditation,
1, IL-6, IL-8, IL-10), IFN-␥ , TNF-␣, and various
which suggest that mindfulness meditation may
measures of cell count. Considered together, these
downregulate the activity of major stress axes
data point to promising areas of future investiga-
in the body, such as the sympathetic–adrenal–
tion, but we caution against exaggerating the posi-
medullary and hypothalamic–pituitary–adrenal
tive effects of mindfulness meditation on immune
axes,21 which are known to influence some of
system dynamics until these effects are further repli-
the immune system mechanisms identified in
cated and additional studies are performed.
this review. To fully realize the benefits of this
With respect to the abovementioned prelimi-
work for improving health, however, additional
nary positive effects that replicated across studies,
RCTs are needed that examine the robustness and

8 Ann. N.Y. Acad. Sci. xxxx (2016) 1–12 

C 2016 New York Academy of Sciences.
Black & Slavich Mindfulness meditation and the immune system

generalizability of the present immune-related protocols, especially with respect to the timing of
findings, as well as their relevance for predicting specimen collection, steps taken for sample pro-
changes in clinical outcomes over time. cessing and storage, and procedures used for assay
Looking forward, there are several points that quantification.
should be considered when planning future stud- In conclusion, across 20 RCTs and more than 1600
ies on mindfulness meditation and immune system participants, we found tentative evidence that mind-
dynamics. First, only 40% of the RCTs reviewed fulness meditation modulates some select immune
used control programs that could account for non- parameters in a manner that suggests a more salu-
specific treatment effects. This leaves substantial togenic immune profile. Specifically, mindfulness
room for improving study designs by using com- meditation appears to be associated with reduc-
parator groups that are better than a waiting-list tions in proinflammatory processes, increases in
control condition. Indeed, a description of a stan- cell-mediated defense parameters, and increases
dardized active control condition that can be used in enzyme activity that guards against cell aging.
alongside MBIs was recently made available for trial Although these findings replicated and are based on
researchers.74 Second, the effects of mindfulness well-designed RCTs, they are restricted to particular
meditation on immune system biomarkers were populations, subgroup analyses, and disease types.
dosage dependent in some instances. As a result, Consequently, additional research is needed to test
beyond obtaining adequate sample sizes, future the effects of mindfulness meditation on immune
studies and interventions will benefit from maxi- system biomarkers to provide a clearer understand-
mizing treatment adherence. This also highlights a ing of the robustness and generalizability of findings,
need for researchers to collect data on individuals’ and to examine the relevance of these findings for
class attendance and/or home practice schedules, clinical symptoms and overall health.
and to report on both the overall effects and dosage-
dependent effects when publishing trial results. Acknowledgments
Third, in the studies reviewed, immune biomark- D.S.B. was supported by a grant from the National
ers were often included as ancillary measures Institute on Aging to the USC/UCLA Center
and, consequently, hypothesis tests were frequently on Biodemography and Population Health (P30
underpowered. To truly advance this area of study, AG017265); G.M.S. was supported by a Society in
future projects will need to power studies and cal- Science–Branco Weiss Fellowship and by a career
ibrate tests for changes in immune parameters as development award from the National Institute of
primary outcomes, a priori, to avoid false nega- Mental Health (K08 MH103443).
tive results. It will also be important to provide
clearer rationales for the immune biomarkers cho- Conflicts of interest
sen for inclusion and better descriptions of how The authors declare no conflicts of interest.
those biomarkers relate to the pathophysiologic
process being studied. Fourth, almost all of the
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