Psychosomatic Medicine

Author’s Accepted Manuscript

Article Title: Mindfulness Training and Physical Health:

Mechanisms and Outcomes

D
Authors: J. David Creswell, Emily K. Lindsay, Daniella K.
Villalba, and Brian Chin

DOI: 10.1097/PSY.0000000000000675

TE
Received Date: June 13, 2018
Revised Date: October 26, 2018
EP
This manuscript has been accepted by the editors of Psychosomatic Medicine, but it has not yet
been copy edited; information within these pages is therefore subject to change. During the copy-
editing and production phases, language usage and any textual errors will be corrected, and pages
will be composed into their final format.

Please visit the journal’s website (www.psychosomaticmedicine.org) to check for a final version
of the article.
C

When citing this article, please use the following: Psychosomatic Medicine (in press) and include
the article’s digital object identifier (DOI).
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Psychosomatic Medicine Publish Ahead of Print
DOI: 10.1097/PSY.0000000000000675

Mindfulness Training and Physical Health: Mechanisms and Outcomes

J. David Creswell, PhD1, Emily K. Lindsay, PhD2, Daniella K. Villalba, PhD1, Brian Chin, MA1

1
Department of Psychology, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA.
2
Department of Psychology, University of Pittsburgh, 210 S. Bouquet Street, Pittsburgh, PA.

D
Corresponding Author. Email: [email protected]. Phone: 412-268-9182.

TE
Conflict of Interest Disclosure: The authors declare no financial conflicts of interest but disclose

that David Creswell’s lab received research funding from the mindfulness company Headspace
EP
for conducting a mindfulness training study in 2018.

This article is based on the Herbert E. Weiner Early Career Award Lecture presented by award

recipient J. David Creswell on March 18, 2017, at the 75th Annual Scientific Meeting of the
C

American Psychosomatic Society in Sevilla, Spain.

C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Abstract

Objective: There has been substantial research and public interest in mindfulness interventions,

biological pathways, and health over the past two decades. This article reviews recent

developments in understanding relationships between mindfulness interventions and physical

health.

D
Methods: A selective review was conducted with the goal of synthesizing conceptual and

TE
empirical relationships between mindfulness interventions and physical health outcomes.

Results: Initial randomized controlled trials (RCTs) in this area suggest that mindfulness
EP
interventions can improve pain management outcomes among chronic pain populations, and

there is preliminary evidence for mindfulness interventions improving specific stress-related

disease outcomes in some patient populations (i.e., clinical colds, psoriasis, IBS, PTSD, diabetes,

HIV). We offer a stress buffering framework for the observed beneficial effects of mindfulness
C

interventions and summarize supporting biobehavioral and neuroimaging studies that provide

plausible mechanistic pathways linking mindfulness interventions with positive physical health
C

outcomes.
A

Conclusion: We conclude with new opportunities for research and clinical implementations to

consider in the next two decades.

Keywords: mindfulness; meditation; randomized controlled trial; mechanisms; health

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Abbreviations: RCT: randomized controlled trial; MBSR: Mindfulness-Based Stress Reduction;

MBCT: Mindfulness-Based Cognitive Therapy; MBRP: Mindfulness-Based Relapse Prevention;

TAU: Treatment-As-Usual; IBS: Irritable bowel syndrome; PTSD: Post-Traumatic Stress

Disorder; CRP: C Reactive Protein; IL-6: Interleukin-6; HPA: Hypothalamic pituitary adrenal;

MAT: Monitor and Acceptance Theory; SAM: Sympathetic adrenal medullary; CBT: Cognitive

D
Behavioral Therapy

TE
EP
C
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
INTRODUCTION

The American Psychosomatic Society and this journal have long supported the development and

testing of mindfulness interventions for improving physical health, publishing some of the initial

high impact theoretical reviews (1) and empirical studies (2–4). Since this early work, there has

been dramatic growth in this area with more high quality randomized controlled trials (RCTs)

D
exploring whether mindfulness interventions can positively influence biopsychosocial and

disease pathogenic processes (5,6). While much of the RCT work has focused on how

TE
mindfulness interventions can improve mental health outcomes (e.g., by lowering risk for

depression relapse in high risk individuals (7)), there are also promising RCTs suggesting that

mindfulness interventions can improve physical health. This review considers the progress our
EP
field has made in studying mindfulness interventions and physical health over the last two

decades. We first introduce mindfulness interventions, then consider outcomes, followed by a

description of mechanistic pathways (biological, behavioral, psychological), and conclude with a

consideration of open questions and opportunities for the field to address in the coming decades.
C

Mindfulness Interventions: What are they?

C
A

The principle aim of mindfulness-based interventions is to foster greater mindfulness,

defined as a process of openly attending, with awareness, to one’s present moment experiences

(5,8,9). This definition of mindfulness, like many others in the literature (8,10,11), describes

mindful awareness as a process of using one’s attention to monitor one’s moment-to-moment

experience through an open lens of equanimity and acceptance (5,12). Mindfulness interventions

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
in the scientific literature appear in many forms, ranging from 3-month residential mindfulness

meditation retreats to brief single-session guided mindfulness exercises (5). The 8-week

Mindfulness-Based Stress Reduction (MBSR) program is the most popular mindfulness

intervention used in the scientific literature, and consists of eight 2.5 hour classes, a day-long

retreat, and daily audio-guided home practice (13). The MBSR program, and many of its variants

(e.g., Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Relapse Prevention

D
(MBRP)), focus on helping individuals learn how to mindfully attend to body sensations and

emotional reactions through the use of guided exercises (e.g., body scan, gentle stretching, seated

TE
meditation) and class discussion. While MBSR dominates the evidence-based scientific

landscape of mindfulness interventions, other forms of mindfulness interventions have been

empirically tested and show promise for improving health-related biomarkers—including

EP
residential mindfulness meditation retreats (14,15), smartphone-delivered mindfulness programs

(16), and brief 3-4 day audio-guided mindfulness training in the laboratory (17).

Despite this surge in mindfulness-based RCTs, most have utilized wait-list or treatment as

usual (TAU) comparison groups. In recent years, though, there has been greater adoption of
C

active treatment comparison programs. These active comparator programs aim to control for

non-mindfulness specific factors such as group and instructor support, positive treatment
C

expectancies, daily home practice, and stress management psychoeducation (5). While wait-list
A

and TAU studies provide an important initial evaluation of whether mindfulness interventions

impact health (cf. 18), active treatment comparators allow for inferences about mindfulness-

specific effects on health. This review aims to highlight some of the new active treatment

controlled mindfulness intervention trials where available.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Mindfulness Interventions and Physical Health: Outcomes

Initial RCTs have demonstrated the potential for mindfulness interventions to improve a

range of stress-related disease-specific outcomes (see Table 1). Here we provide some selective

highlights of these studies (see also relevant reviews 5,19,20). First, several recent large RCTs

show that mindfulness interventions improve pain management outcomes. For example, 8-week

D
mindfulness interventions have been shown to significantly reduce functional disability and

improve pain management in chronic low back pain patients (21–23), chronic pain patients

TE
misusing opioids (22), rheumatoid arthritis patients (24), and fibromyalgia patients (25) (cf. 26).

Two interesting patterns are worth noting in this area. First, there is some initial indication that

mindfulness interventions are superior to health education and social support programs for
EP
treating chronic pain (22–24), but the evidence is mixed regarding whether mindfulness

interventions confer any relative pain treatment advantage over high quality cognitive-behavioral

therapy (CBT) programs (21,24). Second, the durability of treatment effects at follow-up is

unclear. Some RCTs suggest that decreased perceptions of pain (e.g., intensity, severity) can be
C

sustained at follow-ups ranging from three months to one year (21–23), although there is not

strong evidence that functional pain improvements can also be sustained (21,23).
C

Second, several RCTs suggest that mindfulness interventions may impact clinically-
A

relevant stress-related physical health outcomes. There is some initial indication that mindfulness

interventions can accelerate treatment-related skin clearing in psoriasis patients (4) and reduce

post-traumatic stress disorder (PTSD) symptomatology among veterans (27). Similarly, an active

treatment RCT showed decreased susceptibility to (and duration of) colds in a mindfulness

group. However this mindfulness intervention did not significantly decrease the number of

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
overall health care visits or cold-related missed work days (28). A wait-list control RCT showed

decreases in irritable bowel syndrome (IBS) symptomatology immediately after a mindfulness

intervention and at a 6-month follow-up (29,30). Similarly, Garland and colleagues found

decreases in IBS symptomatology after a mindfulness intervention compared to a social support

active control group (29). A recent active treatment RCT showed decreases in insulin resistance

and fasting glucose among individuals at-risk for type 2 diabetes. However, authors reported that

D
class attendance was significantly higher in the mindfulness intervention than in the control

group (31). While, these disease-specific findings are promising, only a handful of RCTs have

TE
examined clinically relevant outcomes in a rigorous way—an opportunity for future research.

Some studies also suggest that mindfulness interventions can buffer declines in CD4+ T

lymphocyte counts among HIV-infected adults (31–33) – a gold-standard clinical measure of

EP
HIV-pathogenesis (34). One critical consideration we have raised is that stress buffering

mechanisms may drive mindfulness intervention effects (35), as stress is known to trigger the

onset or exacerbation of disease pathogenic processes in clinical colds, IBS, diabetes, and HIV

progression. While we discuss these stress buffering mechanisms later in this review, the
C

example of HIV-progression is prudent here in that mindfulness interventions appear to be more

likely to impact CD4+ T lymphocytes among higher stress samples (31–33), compared to lower
C

stress HIV-positive samples (36).

A

There has been significant recent interest in evaluating whether mindfulness interventions

can reduce markers of systemic low-grade inflammation (e.g., C-Reactive Protein (CRP) or

Interleukin-6 (IL-6)). However, the current RCT evidence is mixed. While some RCTs suggest

that mindfulness interventions may reduce IL-6 (14) or CRP (37–39) among older adults and

high stress adults, other studies have failed to show any reduction (IL-6:(37,39,40); CRP: (41).

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Furthermore, while Jedel et al. (2014) reported that a mindfulness intervention reduced CRP,

they questioned its clinical significance given that this reduction in CRP did not lower the

incidence of ulcerative colitis flare-ups. We offer two provisional conclusions in this area. First,

there is not compelling evidence to-date that mindfulness interventions reliably lower markers of

systemic inflammation. Second, it may be that mindfulness interventions reduce inflammation,

but only among participant groups who have significantly elevated inflammatory biology (e.g.,

D
older adults, individuals with inflammatory diseases, or among individuals with high levels of

psychological stress and/or obesity). For example, one methodologically strong trial showed that

TE
mindfulness training buffered stress-induced inflammatory responses in the skin (42).

In summary, there is initial RCT evidence suggesting that mindfulness interventions can

affect physical health. The strongest evidence is in chronic pain conditions, with some promising
EP
initial effects also observed for stress-related disease specific conditions (e.g., psoriasis, IBS,

diabetes, PTSD, HIV). What are needed are more mechanistic RCTs focused on which

components of mindfulness interventions are most effective, and what plausible biobehavioral

processes are engaged that impact health and disease over time. Below we describe some
C

promising biological, behavioral, and psychological mechanisms from recent mindfulness

training RCTs.
C
A

Mindfulness Interventions and Physical Health: Mechanisms

We have developed a mechanistic stress buffering framework positing that mindfulness

interventions train central stress resilience pathways in the brain, which in turn mitigate the

cumulative wear-and-tear that stress (and stress-related health behaviors) can play in

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
exacerbating or accelerating disease pathogenesis across a broad spectrum of stress-related

diseases (35,43,44). A conceptual outline of this framework is shown in Figure 1. One advantage

of this framework is that it describes the conditions under which mindfulness interventions are

most likely to improve physical health, specifically (1) among high stress patient populations,

and (2) when measuring stress-sensitive health and disease outcomes. Indeed, the extant

mindfulness intervention RCT outcomes described above are consistent with this framework, as

D
stress is known to trigger the onset or exacerbation of symptoms in chronic pain, psoriasis, IBS,

PTSD, and diabetes (45). More recently, we have developed theory and research on the

TE
psychological mechanisms for mindfulness intervention effects, positing that the instruction of

acceptance and equanimity skills in mindfulness interventions are critical for fostering stress

resilience and health benefits (16,46). While we have previously described these theoretical
EP
perspectives (5,35,46), here we provide some updates and links to biobehavioral processes

relevant to biobehavioral medicine researchers.

Mindfulness Intervention Mechanisms: Biological Pathways

C

Research from our laboratory suggests that mindfulness interventions train two stress
C

resilience pathways in the brain: (1) increasing activity and functional connectivity in stress
A

regulatory regions of the prefrontal cortex (the regulatory pathway), and (2) decreasing activity

and functional connectivity in regions gating the brain’s stress alarm system (the reactivity

pathway) (35). Regarding the regulatory pathway, we and others have shown that mindfulness

interventions increase the coupling of the resting brain (the so-called default mode network) with

regulatory regions of the prefrontal cortex in the executive control network (14,47,48), while also

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
increasing connectivity strength among regions within the executive control network (49). As

one example, we randomly assigned a sample of stressed unemployed adults to either a 3-day

intensive residential mindfulness training retreat or a well-matched relaxation training retreat,

and found increased coupling of the resting brain (i.e., the posterior cingulate cortex in the

default mode network) with bilateral dorsolateral prefrontal cortex in the mindfulness group, a

coupling effect we did not observe in the relaxation training group (14). A pilot mindfulness

D
training study with veterans found the same brain coupling effect after 16 weeks of mindfulness

training (48). Notably, both studies observed that this increased coupling of regulatory regions in

TE
the prefrontal cortex (dorsolateral prefrontal cortex) was associated with improvements in

markers of health—such as intervention-driven reductions in IL-6 in stressed community adults

(14) and post-traumatic stress disorder (PTSD) symptomatology among veterans (48).
EP
The mindfulness stress buffering framework also posits that mindfulness interventions turn

down the activity and functional connectivity of regions gating the brain’s fight-or-flight

response under stress (the reactivity pathway). The central nucleus of the amygdala has long

been considered an important node for gating the central stress response (50,51), and recent
C

studies suggest that mindful awareness and mindfulness interventions are associated with

modulations in amygdala structure and function (52–55). For example, we have recently shown
C

that mindfulness training decreases stress-related resting state functional connectivity of the
A

amygdala with subgenual anterior cingulate cortex (53), a pathway that may be important in

coordinating the brain’s central fight-or-flight stress response (51).

If mindfulness interventions can foster stress resilience pathways in the brain, they would

also be expected to modulate peripheral sympathetic nervous system and hypothalamic-pituitary-

adrenal (HPA) responses to exogenous stressors (35). Indeed, some initial work suggests that

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
mindfulness interventions can buffer sympathetic nervous system and HPA-axis responses to

acute stress (16,56), although not all RCT studies show sympathetic nervous system and HPA-

axis stress buffering effects (42,57). There are still major questions in this area, such as how

mindfulness interventions impact coping responses under stress (e.g., using approach or

avoidance behaviors; ,58), and whether mindfulness intervention driven stress and coping

responses play an important mechanistic role in explaining stress-related physical health

D
outcomes in patient populations.

TE
Mindfulness Intervention Mechanisms: Health Behavior Pathways

Mindfulness interventions are posited to affect not only stress-related biological

EP
pathways, but also stress-related health behaviors (35). While it is well known that stress is

associated with negative health behaviors such as greater tobacco use, increased difficulty with

smoking cessation, increased likelihood of smoking relapse (59,60), poorer diet and eating

behaviors (60,61), and impaired sleep quality (62), less is known about how mindfulness-based
C

interventions can impact these behaviors. Some of the strongest evidence from RCTs in this area

suggests that mindfulness interventions can reduce substance-use behaviors in at-risk

C

populations, such as cigarette use among heavy smokers (63), drug relapse and alcohol
A

consumption among substance-abusing individuals (64), and opioid misuse among adults

suffering from chronic pain (22). One recent meta-analytic review found that mindfulness-based

treatments reduced substance misuse, substance craving, substance-related stress, and frequency

of post-treatment relapse relative to both TAU and active comparator interventions such as CBT

or relapse prevention treatment (65). Surprisingly, few rigorous RCTs have evaluated whether

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
mindfulness interventions impact diet, sleep, physical exercise, or other salutary health

behaviors. Some initial RCTs suggest that mindfulness interventions can affect eating behaviors,

such as reducing binge eating (66) and sweet consumption (67,68). While initial RCTs indicate

that mindfulness interventions can improve measures of self-reported sleep (69,70), they have

not been shown to be superior to CBT (70), and little research has used objective sleep measures

(e.g., actigraphy or polysomnography) (cf. 71). In summary, more high-quality RCTs are needed

D
to study the effects of mindfulness interventions on health behaviors, in particular studies that

relate changes in health behaviors to alterations in health and disease outcomes.

TE
Mindfulness Intervention Mechanisms: Psychological Pathways
EP
There has been much interest in the psychological mechanisms and pathways linking

mindfulness interventions with health, and prominent models have posited that psychological

processes such as emotion regulation, self-awareness, attentional control, self-reported

mindfulness skills, and decentering may be important mechanisms (72–76). We have taken a
C

different approach, which is consistent with definitions and theory on mindfulness (5,8), by

focusing on the psychological skills taught in mindfulness interventions. Specifically, we have

C

developed Monitor and Acceptance Theory (MAT), which posits that learning how to (1) use
A

one’s attention to monitor present moment experiences while (2) adopting an orientation of

acceptance toward these experiences may be critical psychological mechanisms for mindfulness

intervention effects (46). Indeed, there is initial evidence that self-reported increases in these two

basic mindfulness skills (attention monitoring and acceptance) are related to improvements in

mental health outcomes following mindfulness interventions (77,78). MAT posits that learning

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
acceptance skills is critical for regulating emotion and developing the capacity to be less reactive

to stressful experiences, and that removing acceptance skills training from mindfulness

interventions will attenuate or eliminate their stress buffering health benefits.

We recently tested this MAT prediction in two mindfulness intervention RCTs.

Participants were randomly assigned to (1) mindfulness training that included the standard

attention monitoring and acceptance skills training (Monitor + Accept), (2) mindfulness training

D
that included attention monitoring skills training only (Monitor Only), or (3) control. In both

studies, we observed stress buffering benefits in the Monitor + Accept group compared to the

TE
other groups. Specifically, an 8-week Monitor + Accept mindfulness intervention group showed

significantly greater stress buffering effects on daily life stress perceptions at post-treatment,

compared to a well-matched 8-week Monitor Only mindfulness intervention group and an

EP
assessment only control group (Chin et al., under review). We further controlled for nonspecific

treatment effects (e.g., social contact, instructor effects) in a 2-week smartphone-based

intervention study, showing that Monitor + Accept mindfulness training was significantly more

effective in buffering cortisol and blood pressure reactivity responses to a laboratory stress
C

challenge, compared to both a Monitor Only mindfulness training group and a structurally-

matched placebo control training group (16) (cf. 79). Together, these findings provide promising
C

evidence that acceptance skills training may be a necessary component for driving stress
A

buffering effects in mindfulness interventions, although it is still unknown whether these stress

buffering effects translate into improved stress-related health and disease outcomes over time.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Discussion

Since the early reviews and empirical work published in this journal twenty years ago (e.g.,

1–4), mindfulness intervention research has come a long way. Some of the strongest physical

health RCT evidence to-date suggests that mindfulness interventions can improve pain symptom

management among chronic pain populations, and they may improve some stress-related health

D
and disease outcomes in at-risk populations (e.g., psoriasis, clinical colds, IBS, PTSD, diabetes,

HIV). While there have been some initial efforts at conceptualizing and empirically testing how

TE
mindfulness interventions impact other stress-related diseases that are highly prevalent and drive

a significant burden of health care costs (76,e.g., cardiovascular disease, cancer 80), more high-

quality RCT research is needed evaluating their efficacy and public health impacts. We are also
EP
beginning to identify promising neural, physiological, behavioral, and psychological mechanisms

linking mindfulness interventions with physical health. Our stress buffering framework, and

initial supporting studies, suggest that mindfulness interventions foster two stress resilience

pathways in the brain (the regulatory and reactivity pathways), and can potentially foster
C

regulation of HPA and SAM-axis stress reactivity in ways that may help explain how

mindfulness interventions impact stress-related health and disease outcomes over time (35).
C

Furthermore, our more recent work has focused on the psychological mechanisms for stress
A

buffering effects, showing that acceptance skills training may be a critical component driving

stress resilience effects in mindfulness interventions (16). This mechanistic work suggests new

ways to approach the next generation of RCTs, indicating that mindfulness intervention effects

on physical health may be best observed by measuring stress-sensitive health outcomes among

high stress populations.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 While the first wave of physical health focused RCT studies is promising, our

understanding of mindfulness interventions and physical health still lags behind the larger RCT

literature linking mindfulness interventions with mental health outcomes (5) and there are still

many unanswered questions. Here we enumerate some leading questions in this area, with the

hope that they stimulate new research:

D
1. Do mindfulness interventions have any relative treatment advantages on physical health

compared to other high quality behavioral stress management interventions? While there is

TE
consistent evidence that mindfulness interventions improve health relative to wait-list, treatment

as usual, and some health education programs, the conditions under which mindfulness

interventions provide relative treatment advantages compared to other behavioral treatment

EP
programs, such as CBT (e.g., 21), are currently unclear 1 . In this review we have aimed to

highlight some of the higher quality active treatment controlled RCTs of mindfulness

interventions, but they are still few in number. These trials are important in helping us evaluate

whether there are mindfulness-specific effects above and beyond factors such as group support,
C

relaxation, daily home practice, and placebo expectancies (cf. 82). We suspect that mindfulness

interventions can be efficacious under some circumstances, and our recent work (and others, 83)
C

has focused on the most stringent treatment controlled approach to date—namely pitting two
A

different forms of mindfulness intervention against each other in a dismantling study approach

(16).

1 There are multiple ways to operationalize relative treatment advantages, and while our discussion has
focused on the overall magnitude of health improvements, it is important to note that this can also be
measured via cost-effectiveness. Group-based MBSR may be more cost effective compared to
individually-focused treatments (81).

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 2. Do stress buffering pathways explain how mindfulness interventions impact physical

health outcomes? While we have outlined some promising RCT evidence for a stress buffering

mechanistic framework, which explains the biological embedding of mindfulness interventions,

it is certainly possible that other pathways may provide a better evidence-based framework of

mindfulness intervention physical health effects. For example, mindfulness interventions also

boost positive emotions (e.g., (84,85) and social connections (37,86,87) that may ultimately

D
improve physical health outcomes. Indeed, positive affectivity and positive social relationship

processes are known to independently promote physical health outcomes (88,89). The effects of

TE
mindfulness on positive emotions and social relationships may be directly associated with health,

or may still operate through stress buffering pathways (i.e., mindfulness improves positive affect

and social functioning, which lowers stress, and ultimately improves health outcomes).
EP
3. What is the necessary mindfulness intervention dose for physical health benefits? As

described in this review, the current evidence base indicates that 8-week mindfulness

interventions can impact physical health outcomes—but do smaller intervention doses have
C

benefits? Although brief mindfulness interventions and inductions lasting two weeks or less

show small overall effects in reducing negative affect and distress (e.g., 90) and in buffering
C

stimulated pain responses (17), at least two weeks of daily mindfulness training may be needed
A

to see biological stress buffering effects (16). Furthermore, intervention dosing likely depends on

participant factors, quality of mindfulness practice, and specific outcomes measured.

4. How long do mindfulness intervention effects last following intervention? There are

currently few high quality RCTs that include follow-up assessments, and these studies provide

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
mixed evidence. Some studies show maintenance of post-treatment effects (e.g., 27), some

studies show no relative treatment advantage of mindfulness interventions at post-treatment but

show advantages at longer-term follow-up assessments (e.g., 64), and yet other studies show

immediate post-treatment benefits that degrade at follow-up assessments (e.g., 23). One

explanation for these divergent effects is that some participants complete daily home practice

and incorporate mindfulness skills into their daily lives during and after the intervention in ways

D
that might propagate intervention effects over time. It will be important for future RCTs to find

effective ways of measuring continued mindfulness practices (formal and informal) both during

TE
mindfulness interventions and in subsequent follow-up periods to test whether these practice

variables explain health effects over time.

EP
5. Do smartphone and online mindfulness interventions improve physical health? There is

tremendous public interest in smartphone and online mindfulness interventions (e.g., Headspace,

Brightmind, Calm), although almost no published studies have evaluated how these programs

affect health. These programs do have certain advantages relative to 8-week group-based
C

mindfulness programs—they are widely available, they can be delivered remotely to hard-to-

reach individuals who own smartphones, and they are relatively inexpensive. To our knowledge,
C

our recent 14-day smartphone study is the first to link a remote mindfulness intervention with
A

biomarkers of health (i.e., cortisol and blood pressure reactivity) (16). Given their popularity,

more research is needed to test the efficacy of these mindfulness interventions for health

outcomes, patients’ motivation for engaging in these programs, as well as the safety of these

stress management interventions with minimal instructor support.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 Conclusions

An early review in this journal began with the title, ―What do we really know about

mindfulness-based stress reduction?‖ (1). We certainly know a great deal more now about the

effects of MBSR and other mindfulness interventions on physical health, but many questions

remain. There is a significant need for high quality RCTs in this area, as many clinicians are now

D
using mindfulness-based therapeutic approaches, and large numbers of individuals are seeking

out mindfulness programs online or in their communities. We believe that Psychosomatic

TE
Medicine is well poised to advance these research efforts in the coming decades.
EP
C
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Acknowledgments

Portions of this manuscript were presented at the 2017 American Psychosomatic Society annual

conference in Seville, Spain as part of David Creswell’s APS Herbert Weiner Early Career

Award address. The writing of this manuscript was supported in part by grants from the

National Center for Complementary & Integrative Health (NCCIH) of the National Institutes of

D
Health (R21AT008493, R01AT008685, F32AT009508). The content is solely the responsibility

of the authors and does not necessarily represent the official views of the National Institutes of

TE
Health. We thank the members of the Health and Human Performance Laboratory at Carnegie

Mellon University for all their help and support in conducting this work on mindfulness

interventions.
EP
C
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
References

1. Bishop SR. What do we really know about mindfulness-based stress reduction?

Psychosomatic Medicine. 2002;64:71–83.

2. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to

D
quality of life, mood, symptoms of stress, and immune parameters in breast and prostate

cancer outpatients. Psychosomatic Medicine. 2003;65:571–81.

TE
3. Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF,

Urbanowski F, Harrington A, Bonus K, Sheridan JF. Alterations in brain and immune

function produced by mindfulness meditation. Psychosomatic medicine. 2003;65:564–570.

EP
4. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley TG, Hosmer D, Bernhard

JD. Influence of a mindfulness meditation-based stress reduction intervention on rates of

skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB)
C

and photochemotherapy (PUVA). Psychosomatic Medicine. 1998;60:625–632.

5. Creswell JD. Mindfulness Interventions. Annual Review of Psychology. 2017;68:491–516.

C

6. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. The Journal of the American Medical
A

Association. 2008;300:1350–52.

7. Kuyken W, Warren FC, Taylor RS, Whalley B, Crane C, Bondolfi G, Hayes R, Huijbers M,

Ma H, Schweizer S, Segal Z, Speckens A, Teasdale JD, Van Heeringen K, Williams M,

Byford S, Byng R, Dalgleish T. Efficacy of Mindfulness-Based Cognitive Therapy in

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From

Randomized Trials. JAMA Psychiatry. 2016;73:565.

8. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, Segal ZV, Abbey S,

Speca M, Velting D, Devins G. Mindfulness: A Proposed Operational Definition. Clinical

Psychology: Science and Practice. 2004;11:230–241.

D
9. Brown KW, Ryan RM, Creswell JD. Mindfulness: Theoretical foundations and evidence for

its salutary effects. Psychological Inquiry. 2007;18:211–237.

TE
10. Quaglia JT, Brown KW, Lindsay EK, Creswell JD, Goodman RJ. From conceptualization to

operationalization of mindfulness. In: Handbook of Mindfulness: New York: Guilford

Press; 2014.
EP
11. Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face

stress, pain, and illness. New York, NY: Delta; 1990.

C

12. Lindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and Acceptance

Theory (MAT). Clinical Psychology Review. 2017;51:48–59.

C

13. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based

on the practice of mindfulness meditation: Theoretical considerations and preliminary

A

results. General Hospital Psychiatry. 1982;4:33–47.

14. Creswell JD, Taren AA, Lindsay EK, Greco CM, Gianaros PJ, Fairgrieve A, Marsland AL,

Brown KW, Way BM, Rosen RK. Alterations in resting-state functional connectivity link

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 mindfulness meditation with reduced interleukin-6: a randomized controlled trial.

Biological psychiatry. 2016;80:53–61.

15. Epel ES, Puterman E, Lin J, Blackburn EH, Lum PY, Beckmann ND, Zhu J, Lee E, Gilbert

A, Rissman RA, Tanzi RE, Schadt EE. Meditation and vacation effects have an impact on

disease-associated molecular phenotypes. Translational Psychiatry. 2016;6:e880.

D
16. Lindsay EK, Young S, Smyth JM, Brown KW, Creswell JD. Acceptance lowers stress

reactivity: Dismantling mindfulness training in a randomized controlled trial.

TE
Psychoneuroendocrinology. 2018;87:63–73.

17. Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, Coghill RC. Mindfulness

Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and
EP
Sham Mindfulness Meditation-Induced Analgesia. Journal of Neuroscience.

2015;35:15307–25.

18. Freedland KE. Demanding Attention: Reconsidering the Role of Attention Control Groups in
C

Behavioral Intervention Research. Psychosomatic Medicine. 2013;75:100–102.

C

19. Goyal M, Singh S, Sibinga EM, Gould NF, Rowland-Seymour A, Sharma R, Berger Z,

Sleicher D, Maron DD, Shihab HM, Ranasinghe PD, Linn S, Saha S, Bass EB,
A

Haythornthwaite JA. Meditation programs for psychological stress and well-being: a

systematic review and meta-analysis. JAMA Internal Medicine. 2014;174:357–368.

20. Black DS, Slavich GM. Mindfulness meditation and the immune system: a systematic review

of randomized controlled trials. Annals of the New York Academy of Sciences. 2016;1–12.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
21. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE,

Turner JA. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy

or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back

Pain: A Randomized Clinical Trial. JAMA. 2016;315:1240–1249.

22. Garland EL, Manusov EG, Froeliger B, Kelly A, Williams JM, Howard MO. Mindfulness-

D
oriented recovery enhancement for chronic pain and prescription opioid misuse: Results

from an early-stage randomized controlled trial. Journal of Consulting and Clinical

TE
Psychology. 2014;82:448–59.

23. Morone NE, Greco CM, Moore CG, Rollman BL, Lane B, Morrow LA, Glynn NW, Weiner

DK. A mind-body program for older adults with chronic low back pain: A randomized
EP
clinical trial. JAMA Internal Medicine. 2016;176:329–37.

24. Davis MC, Zautra AJ, Wolf LD, Tennen H, Yeung EW. Mindfulness and cognitive–

behavioral interventions for chronic pain: Differential effects on daily pain reactivity and
C

stress reactivity. Journal of Consulting and Clinical Psychology. 2015;83:24–35.

25. Van Gordon W, Shonin E, Dunn TJ, Garcia-Campayo J, Griffiths MD. Meditation awareness
C

training for the treatment of fibromyalgia syndrome: A randomized controlled trial. British

Journal of Health Psychology. 2017;22:186–206.

A

26. Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia

with mindfulness-based stress reduction: Results from a 3-armed randomized controlled

trial. PAIN®. 2011;152:361–69.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
27. Polusny MA, Erbes CR, Thuras P, Moran A, Lamberty GJ, Collins RC, Rodman JL, Lim

KO. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans:

A randomized clinical trial. JAMA. 2015;314:456–65.

28. Barrett B, Hayney MS, Muller D, Rakel D, Ward A, Obasi CN, Brown R, Zhang Z, Zgierska

A, Gern J, West R, Ewers T, Barlow S, Gassman M, Coe CL. Meditation or Exercise for

D
Preventing Acute Respiratory Infection: A Randomized Controlled Trial. The Annals of

Family Medicine. 2012;10:337–46.

TE
29. Garland EL, Gaylord SA, Palsson O, Faurot K, Douglas Mann J, Whitehead WE.

Therapeutic mechanisms of a mindfulness-based treatment for IBS: effects on visceral

sensitivity, catastrophizing, and affective processing of pain sensations. Journal of

EP
Behavioral Medicine. 2012;35:591–602.

30. Zernicke KA, Campbell TS, Blustein PK, Fung TS, Johnson JA, Bacon SL, Carlson LE.

Mindfulness-Based Stress Reduction for the Treatment of Irritable Bowel Syndrome

C

Symptoms: A Randomized Wait-list Controlled Trial. International Journal of Behavioral

Medicine. 2013;20:385–96.
C

31. Creswell JD, Myers HF, Cole SW, Irwin MR. Mindfulness meditation training effects on

CD4+ T lymphocytes in HIV-1 infected adults: A small randomized controlled trial. Brain
A

Behavior and Immunity. 2009;23:184–188.

32. Gonzalez-Garcia M, Ferrer MJ, Borras X, Muñoz-Moreno JA, Miranda C, Puig J, Perez-

Alvarez N, Soler J, Feliu-Soler A, Clotet B, Fumaz CR. Effectiveness of Mindfulness-

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 Based Cognitive Therapy on the Quality of Life, Emotional Status, and CD4 Cell Count of

Patients Aging with HIV Infection. AIDS and Behavior. 2013;18:676–85.

33. SeyedAlinaghi S, Jam S, Foroughi M, Imani A, Mohraz M, Djavid GE, Black DS.

Randomized Controlled Trial of Mindfulness-Based Stress Reduction Delivered to Human

Immunodeficiency Virus–Positive Patients in Iran: Effects on CD4+ T Lymphocyte Count

D
and Medical and Psychological Symptoms. Psychosomatic Medicine. 2012;74:620–27.

34. McCune JM. The dynamics of CD4+ T-cell depletion in HIV disease. Nature.

TE
2001;410:974–79.

35. Creswell JD, Lindsay EK. How does mindfulness training affect health? A mindfulness

stress buffering account. Current Directions in Psychological Science. 2014;23:401–7.

EP
36. Hecht FM, Moskowitz JT, Moran P, Epel ES, Bacchetti P, Acree M, Kemeny ME, Mendes

WB, Duncan LG, Weng H, Levy JA, Deeks SG, Folkman S. A Randomized, Controlled

Trial of Mindfulness-Based Stress Reduction in HIV Infection. Brain, Behavior, and

C

Immunity [Internet]. in press.

C

37. Creswell JD, Irwin MR, Burklund LJ, Lieberman MD, Arevalo JMG, Ma J, Breen EC, Cole

SW. Mindfulness-Based Stress Reduction training reduces loneliness and pro-inflammatory

A

gene expression in older adults: A small randomized controlled trial. Brain, Behavior, and

Immunity. 2012;26:1095–1101.

38. Jedel S, Hoffman A, Merriman P, Swanson B, Voigt R, Rajan KB, Shaikh M, Li H,

Keshavarzian A. A Randomized Controlled Trial of Mindfulness-Based Stress Reduction to

Prevent Flare-Up in Patients with Inactive Ulcerative Colitis. Digestion. 2014;89:142–55.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
39. Malarkey WB, Jarjoura D, Klatt M. Workplace based mindfulness practice and

inflammation: A randomized trial. Brain, Behavior, and Immunity. 2013;27:145–54.

40. Bower JE, Crosswell AD, Stanton AL, Crespi CM, Winston D, Arevalo J, Ma J, Cole SW,

Ganz PA. Mindfulness meditation for younger breast cancer survivors: A randomized

controlled trial: Mindfulness for Young Cancer Survivors. Cancer. 2015;121:1231–40.

D
41. Fogarty FA, Booth RJ, Gamble GD, Dalbeth N, Consedine NS. The effect of mindfulness-

based stress reduction on disease activity in people with rheumatoid arthritis: a randomised

TE
controlled trial. Annals of the Rheumatic Diseases. 2015;74:472–74.

42. Rosenkranz MA, Davidson RJ, MacCoon DG, Sheridan JF, Kalin NH, Lutz A. A

comparison of mindfulness-based stress reduction and an active control in modulation of

EP
neurogenic inflammation. Brain, Behavior, and Immunity. 2013;27C:174–84.

43. Creswell JD. Biological pathways linking mindfulness with health. In: Handbook of

Mindfulness: Theory, Research, and Practice. New York, NY: Guilford Press; 2014.
C

44. Erickson KI, Creswell JD, Verstynen TD, Gianaros PJ. Health Neuroscience: Defining a
C

New Field. Current Directions in Psychological Science. 2014;23:446–53.

45. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. Journal of the
A

American Medical Association. 2007;298:1685–87.

46. Lindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and Acceptance

Theory (MAT). Clinical Psychology Review. 2017. p. 48–59.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
47. Brewer JA, Worhunsky PD, Gray JR, Tang Y-Y, Weber J, Kober H. Meditation experience

is associated with differences in default mode network activity and connectivity.

Proceedings of the National Academy of Sciences. 2011;108:20254–59.

48. King AP, Erickson TM, Giardino ND, Favorite T, Rauch SAM, Robinson E, Kulkarni M,

Liberzon I. A Pilot Study of Group Mindfulness-Based Cognitive Therapy (mbct) for

D
Combat Veterans with Posttraumatic Stress Disorder (ptsd). Depression and Anxiety.

2013;30:638–645.

TE
49. Taren AA, Gianaros PJ, Greco CM, Lindsay EK, Fairgrieve A, Brown KW, Rosen RK,

Ferris JL, Julson E, Marsland AL, Creswell JD. Mindfulness meditation training and

executive control network resting state functional connectivity: A randomized controlled

EP
trial. Psychosomatic Medicine. 2017;79:674–683.

50. Ulrich-Lai YM, Herman JP. Neural regulation of endocrine and autonomic stress responses.

Nature Reviews Neuroscience. 2009;10:397–409.

C

51. Arnsten AFT. Stress signalling pathways that impair prefrontal cortex structure and function.

Nature Reviews Neuroscience. 2009;10:410–22.

C

52. Hölzel BK, Carmody J, Evans KC, Hoge EA, Dusek JA, Morgan L, Pitman RK, Lazar SW.
A

Stress reduction correlates with structural changes in the amygdala. Social Cognitive and

Affective Neuroscience. 2010;5:11–17.

53. Taren AA, Gianaros PJ, Greco CM, Lindsay EK, Fairgrieve A, Brown KW, Rosen RK,

Ferris JL, Julson E, Marsland AL, Bursley JK, Ramsburg J, Creswell JD. Mindfulness

meditation training alters stress-related amygdala resting state functional connectivity: a

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 randomized controlled trial. Social Cognitive and Affective Neuroscience. 2015;10:1758–

68.

54. Taren AA, Creswell JD, Gianaros PJ. Dispositional Mindfulness Co-Varies with Smaller

Amygdala and Caudate Volumes in Community Adults. PLoS ONE. 2013;8:e64574.

55. Way BM, Creswell JD, Eisenberger NI, Lieberman MD. Dispositional mindfulness and

D
depressive symptomatology: Correlations with limbic and self-referential neural activity

during rest. Emotion. 2010;10:12–24.

TE
56. Nyklíček I, Van Beugen S, Van Boxtel GJ. Mindfulness-Based Stress Reduction and

Physiological Activity During Acute Stress: A Randomized Controlled Trial. Health

Psychology. 2013;32:1110–13.
EP
57. Creswell JD, Pacilio LE, Lindsay EK, Brown KW. Brief mindfulness meditation training

alters psychological and neuroendocrine responses to social evaluative stress.

Psychoneuroendocrinology. 2014;44:1–12.
C

58. Weinstein N, Brown KW, Ryan RM. A multi-method examination of the effects of
C

mindfulness on stress attribution, coping, and emotional well-being. Journal of Research in

Personality. 2009;43:374–85.
A

59. Cohen S, Lichtenstein E. Perceived stress, quitting smoking, and smoking relapse. Health

Psychology. 1990;9:466.

60. Ng DM, Jeffery RW. Relationships Between Perceived Stress and Health Behaviors in a

Sample of Working Adults. Health Psychology. 2003;22:638–42.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
61. Groesz LM, McCoy S, Carl J, Saslow L, Stewart J, Adler N, Laraia B, Epel E. What is eating

you? Stress and the drive to eat. Appetite. 2012;58:717–21.

62. Becker NB, De Jesus SN, Marguilho R, Viseu J, Del Rio KA, Buela-Casal G. Sleep quality

and stress: A literature review. In: Advanced Research in Health, Education and Social

Sciences: Towards a better practice. Sibiu, Romania: Editura Universitară; 2015.

D
63. Brewer JA, Mallik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, Minnix-Cotton CA,

Byrne SA, Kober H, Weinstein AJ, Carroll KM, Rounsaville BJ. Mindfulness training for

TE
smoking cessation: Results from a randomized controlled trial. Drug & Alcohol

Dependence. 2011;119:72–80.

64. Bowen S, Witkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, Carroll HA, Harrop E,
EP
Collins SE, Lustyk K, Larimer ME. Relative efficacy of mindfulness-based relapse

prevention, standard relapse prevention, and treatment as usual for substance use disorders:

A randomized clinical trial. JAMA Psychiatry. 2014;71:547–56.

C

65. Li W, Howard MO, Garland EL, McGovern P, Lazar M. Mindfulness treatment for

substance misuse: A systematic review and meta-analysis. Journal of Substance Abuse

C

Treatment. 2017;75:62–96.
A

66. O’Reilly GA, Cook L, Spruijt-Metz D, Black DS. Mindfulness-based interventions for

obesity-related eating behaviours: a literature review: Mindfulness interventions for eating

behaviours. Obesity Reviews. 2014;15:453–61.

67. Mason AE, Epel ES, Aschbacher K, Lustig RH, Acree M, Kristeller J, Cohn M, Dallman M,

Moran PJ, Bacchetti P, Laraia B, Hecht FM, Daubenmier J. Reduced reward-driven eating

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 accounts for the impact of a mindfulness-based diet and exercise intervention on weight

loss: Data from the SHINE randomized controlled trial. Appetite. 2016;100:86–93.

68. Mason AE, Epel ES, Kristeller J, Moran PJ, Dallman M, Lustig RH, Acree M, Bacchetti P,

Laraia BA, Hecht FM, Daubenmier J. Effects of a mindfulness-based intervention on

mindful eating, sweets consumption, and fasting glucose levels in obese adults: data from

D
the SHINE randomized controlled trial. Journal of Behavioral Medicine. 2015;1–13.

69. Black DS, O’Reilly GA, Olmstead R, Breen EC, Irwin MR. Mindfulness Meditation and

TE
Improvement in Sleep Quality and Daytime Impairment Among Older Adults With Sleep

Disturbances: A Randomized Clinical Trial. JAMA Internal Medicine. 2015;175:494.

70. Garland SN, Carlson LE, Stephens AJ, Antle MC, Samuels C, Campbell TS. Mindfulness-
EP
Based Stress Reduction Compared With Cognitive Behavioral Therapy for the Treatment of

Insomnia Comorbid With Cancer: A Randomized, Partially Blinded, Noninferiority Trial.

Journal of Clinical Oncology. 2014;32:1–9.

C

71. Britton WB, Haynes PL, Fridel KW, Bootzin RR. Polysomnographic and Subjective Profiles

of Sleep Continuity Before and After Mindfulness-Based Cognitive Therapy in Partially

C

Remitted Depression: Psychosomatic Medicine. 2010;72:539–48.

A

72. Bernstein A, Hadash Y, Lichtash Y, Tanay G, Shepherd K, Fresco DM. Decentering and

Related Constructs A Critical Review and Metacognitive Processes Model. Perspectives on

Psychological Science. 2015;10:599–617.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
73. Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How Does

Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and

Neural Perspective. Perspectives on Psychological Science. 2011;6:537–59.

74. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. Journal of

Clinical Psychology. 2006;62:373–86.

D
75. Vago DR, Silbersweig DA. Self-awareness, self-regulation, and self-transcendence (S-ART):

a framework for understanding the neurobiological mechanisms of mindfulness. Frontiers

TE
in Human Neuroscience.

76. Loucks EB, Schuman-Olivier Z, Britton WB, Fresco DM, Desbordes G, Brewer JA, Fulwiler

C. Mindfulness and Cardiovascular Disease Risk: State of the Evidence, Plausible

EP
Mechanisms, and Theoretical Framework. Current Cardiology Reports. 2015;17:112.

77. Gu J, Strauss C, Bond R, Cavanagh K. How do mindfulness-based cognitive therapy and

mindfulness-based stress reduction improve mental health and wellbeing? A systematic

C

review and meta-analysis of mediation studies. Clinical Psychology Review. 2015;37:1–12.

C

78. Quaglia JT, Braun SE, Freeman SP, McDaniel MA, Brown KW. Meta-analytic evidence for

effects of mindfulness training on dimensions of self-reported dispositional mindfulness.

A

Psychological Assessment. 2016;28:803.

79. Engert V, Kok BE, Papassotiriou I, Chrousos GP, Singer T. Specific reduction in cortisol

stress reactivity after social but not attention-based mental training. Science Advances.

2017;3:e1700495.

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
80. Carlson LE, Doll R, Stephen J, Faris P, Tamagawa R, Drysdale E, Speca M. Randomized

Controlled Trial of Mindfulness-Based Cancer Recovery Versus Supportive Expressive

Group Therapy for Distressed Survivors of Breast Cancer (MINDSET). Journal of Clinical

Oncology. 2013;31:3119–26.

81. Cherkin DC, Herman PM. Cognitive and Mind-Body Therapies for Chronic Low Back Pain

D
and Neck Pain: Effectiveness and Value. JAMA Internal Medicine.

82. Sevinc G, Hölzel BK, Hashmi J, Greenberg J, McCallister A, Treadway M, Schneider ML,

TE
Dusek JA, Carmody J, Lazar SW. Common and Dissociable Neural Activity After

Mindfulness-Based Stress Reduction and Relaxation Response Programs. Psychosomatic

Medicine. 2018;80:439–51.
EP
83. Britton WB, Davis JH, Loucks EB, Peterson B, Cullen BH, Reuter L, Rando A, Rahrig H,

Lipsky J, Lindahl JR. Dismantling Mindfulness-Based Cognitive Therapy: Creation and

validation of 8-week focused attention and open monitoring interventions within a 3-armed
C

randomized controlled trial. Behaviour Research and Therapy.

84. Geschwind N, Peeters F, Drukker M, van Os J, Wichers M. Mindfulness training increases

C

momentary positive emotions and reward experience in adults vulnerable to depression: a

randomized controlled trial. Journal of Consulting and Clinical Psychology. 2011;79:618.

A

85. Lindsay EK, Chin B, Greco CM, Young S, Brown KW, Wright AGC, Smyth JS, Burkett D,

Creswell JD. How mindfulness training promotes positive emotions: Dismantling monitor

and acceptance in two randomized controlled trials. Journal of Personality and Social

Psychology. in press;

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
86. Carson JW, Carson KM, Gil KM, Baucom DH. Mindfulness-based relationship

enhancement. Behavior Therapy. 2004;35:471–494.

87. Lim D, Condon P, DeSteno D. Mindfulness and Compassion: An Examination of

Mechanism and Scalability. PLoS ONE. 2015;10:e0118221.

88. Cohen S. Social relationships and health. American psychologist. 2004;59:676.

D
89. Pressman SD, Cohen S. Does positive affect influence health? Psychological bulletin.

TE
2005;131:925.

90. Schumer MC, Lindsay EK, Creswell JD. Brief mindfulness for negative affectivity: a

systematic review and meta-analysis. Journal of Consulting and Clinical Psychology. in

EP
press;
C
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Figure Captions

Figure 1. Plausible pathways linking mindfulness interventions with physical health.

Mindfulness interventions, which train skills in monitoring present-moment experience with an

orientation of acceptance, are proposed to impact physical health primarily among high-stress

populations. Stress-buffering pathways in the brain, peripheral physiology, and subjective

experience are posited to increase coping resources, which buffer recurrent, exaggerated, or

D
dysregulated biological stress responses and negative health behaviors. Specifically, mindfulness

interventions increase activity and connectivity in regulatory prefrontal cortex brain regions (the

TE
top-down regulatory pathway) and decrease reactivity and connectivity in regions that gate the

body’s fight-or-flight stress response (the bottom-up reactivity pathway). These neural changes

alter stress appraisals, decrease physiological stress reactivity in the sympathetic nervous system
EP
and hypothalamic-pituitary-adrenal (HPA) axis, and impact coping and health behaviors.

Together, changes in neural and physiological stress responding, stress appraisals, coping, and

health behaviors may be important mechanisms for improvements in stress-related disease

outcomes observed following mindfulness interventions. Pathways outlined in dotted gray lines
C

represent theorized mechanisms for future research.

C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Figure 1

D
TE
EP
C
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Table 1. Randomized controlled trials examining the effect of mindfulness interventions on health outcomes
Mindfulness Comparison Follow-up
Reference Population Outcome Direction of Findings
Intervention Group(s) Time Point
Cherkin et al Adults with 8-week MBSR UC Pain 6-mo 

D
(2016) chronic low back 12-mo 
pain Functional 6-mo 
Disability 12-mo 
CBT Pain 6-mo no differences

TE
12-mo no differences
Functional 6-mo no differences
Disability 12-mo no differences
Morone et al Older adults with 8-week MBSR HEP Pain Immediate 
(2016) chronic low back 6-mo 
pain Functional Immediate 
Disability 6-mo no differences

EP
Garland et al Chronic pain 8-week MORE Social Support Pain Immediate 
(2014) patients addicted 3-mo 
to opioids Desire for Immediate 
opioids 3-mo no differences
Davis et al RA patients 8-week Mindful CBT-P Daily pain Immediate 
(2015) Awareness &
Acceptance Arthritis Daily pain Immediate 
C
Education
Van Gordon Fibromyalgia 8-week Meditation CBT for Groups Pain Immediate 
et al (2017) patients Awareness 6-mo 
C
Training FMS Immediate 
6-mo 
Schmidt et al Female 8-week MBSR Active Control FMS Immediate no change
(2011) fibromyalgia Wait-List FMS Immediate no change
A

patients
Barrett et al Healthy 8-week MBSR Exercise Program ARI 
(2012) community adults (incidence,
duration,

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
 severity)
No Treatment ARI 
Control (incidence,
duration,
severity)

D
Kabat-Zinn et Psoriasis patients Ultraviolet light Ultraviolet light Psoriasis Immediate 
al (1998) therapy + audio therapy only lesions
MBSR

TE
Garland et al IBS female 8-week MBSR Support Group IBS Immediate 
(2012) patients symptom
severity Immediate 
Pain
catastrophiz
ing
Zernicke et al IBS patients 8-week MBSR UC IBS Immediate 

EP
(2013) symptom 6-mo no differences
severity Immediate no differences
Quality of 6-mo no differences
Life
Shomaker et Adolescent girls at 6-week CBT Insulin Immediate 
al (2017) risk for type 2 Mindfulness resistance 6-mo 
diabetes training Fasting Immediate 
C
insulin 6-mo 
Creswell et al HIV patients 8-week MBSR 1-day Seminar CD4+ Immediate 
(2009)
Gonzalez- HIV patients 8-week MBCT UC CD4+ Immediate no differences
C
Garcia et al 3-mo 
(2013)
Seyed et al HIV patients 8-week MBSR Education & CD4+ Immediate 
(2012) Support Group 3-mo 
A

6-mo 
9-mo 
12-mo no differences

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Creswell et al Unemployed 3-day MBSR 3-day Relaxation IL-6 4-mo 
(2016) community adults retreat retreat
Creswell et al Lonely older 8-week MBSR Wait-List CRP Immediate no differences
(2012) adults IL-6 Immediate (marginal)
Jedel et al Ulcerative colitis 8-week MBSR Education CRP 12-mo (among flared)

D
(2014) patients IL-6 12-mo no differences
Malarkey et al Adults at-risk for 6-week MBSR Lifestyle CRP Immediate (marginal)
(2015) cardiovascular Education 6-mo no differences

TE
disease IL-6 Immediate no differences
6-mo no differences
Fogarty et al RA patients 8-week MBSR Wait-List CRP Immediate no differences
(2015)
Bower et al Young breast 6-week MAPS Wait-List CRP Immediate
no change
(2015) cancer survivors IL-6 (among high
Immediate
compliance subgroup)

EP
The table is organized so that trials examining similar or related health outcomes are clustered together. The Reference column
provides information about the authors; the Population column indicates whether data was obtained from healthy or specific clinical
samples; the Mindfulness Intervention column refers to the length and type of mindfulness intervention used; the Comparison
Group(s) column refers to the type of control group; the Outcome column indicates the primary outcome of interest for this review;
the Follow-up Time Point column provides information about the presence of follow-up measures and how long after the interventions
these measures were obtained; and the Direction of Findings column indicates whether there was an increase, decrease, or no change
in health-related outcomes in the mindfulness group relative to the control group. Abbreviations. ARI: Acute Respiratory Infection;
C
CBT: Cognitive Behavioral Therapy; CBT-P: Cognitive Behavioral Therapy for Pain; CD4+: CD4+ T-lymphocyte cell count; CRP:
C-Reactive Protein; FMS: Fibromyalgia Symptoms; HEP: Health Enhancement Program; IBS: Irritable Bowel Syndrome; IL-6:
Interleukin-6; MAPS: Mindful Awareness Practices; MBCT: Mindfulness-Based Cognitive Therapy; MBSR: Mindfulness Based
Stress Reduction; MORE: Mindfulness-Oriented Recovery Enhancement; RA: Rheumatoid Arthritis; UC: Usual Care.
C
A

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.