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Meditation and Depression

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Meditation and Depression
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8/10/17 11:05 PM
So as a result of a recent discussion in this thread  I got to thinking about the connection between mediation and depression. Being kind of into fact-based analysis, I did a quick literature search in Google Scholar and came up with some interesting results. Basically, mediation, exercise, and behavioral therapy all work about equally the same as drugs in helping to relieve depression, according to the literature. There is some evidence for a genetic effect of drugs, but I could not find the article I cited in the thread that I thought I had seen regarding the effect of genetics on responsivness to talk therapy. There is also a recent study showing that the microbiome has an impact on emotional state, and that probiotics help reduce depression.

Based on this, I would modify my advice to someone with major depression to, first and most importantly, work with a therapist so you have an objective opinion about your emotional state, and also a trained teacher if you try meditation. Then try meditation, exercise (yoga for example), talk therapy and even probiotics before you try drugs. Drugs are expensive and they don't seem to work much better than other, far cheaper methods. The cheaper methods do take more time and committment though, well maybe with the exception of probiotics.

I did a blog post with more, you can read about it here.

Comments?

RE: Meditation and Depression
Answer
8/11/17 8:22 AM as a reply to svmonk.
I'm going to take a "Buddhist" lens here & say that meditation, medication, therapy & healthy living are all under the eightfold path umbrella (in a modern, adaptable & realistic sense).  Most 'success stories' within pragmatic dharma involve a lot off off cushion, informal practice, which to me suggests already that calling it meditation is inadequate.

Mental illness is the same thing (on the ground level, not in an academic debate) as the defilements.  As the hindrances are penetrated with clear seeing, one becomes equanimous to them.  Later, it ones practice matures enough, they can practice manipulative techniques like antidoting & analytical meditation without those things becoming undermined by conceptualization & striving.  Eventually, these practices dig into the roots of the hindrances, which are called the fetters.

Learning to uproot negative thoughts & emotions is not enough.  Conduct change on a massive scale is required.  Unfortunately this seems less "sexy" than sitting meditation, so few do it. It is not any type of conduct change - nor is it generic.  It involves a large amount of sati & dhamma vicaya to determine what is causing stress, objectively & subjectively, then how to change that.  Conduct change can not properly occur until one is free from the hindrances (access concentration in some contexts).

These are the types of practices which have permanent effects on mental illness.  They include therapy & meditation, but also more.

RE: Meditation and Depression
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8/11/17 1:28 PM as a reply to svmonk.
I certainly think you're going in the right direction, svmonk. Unrealistic expectations about meditation may lead to failure, which in turn precipitates even worse depression. The whole thing has to be studied on an objective and scientific basis.

A lot of the early studies of the clinical effectiveness of meditation were carried out by the TM people. As the authors of your metastudy note, there are reasons to doubt the validity of those studies. But that doesn't prove, of course, that TM is therefore ineffective! It may turn out that simple mantra meditation genuinely is more effective for depression than the mindfulness type of meditation. We don't have enough evidence to say.

RE: Meditation and Depression
Answer
8/11/17 10:28 PM as a reply to Noah D.
Hi Noah,

Right, good point. My former Zen teacher (who sadly now suffers from Alzheimers and is no longer teaching) talked alot about these kinds of behavioral issues and how to work with them as part of Dharma practice. She talked alot about judgement in particular, which she said she struggled with for years. She never talked about the kinds of state changes that come with the paths, as that is really not something Zen folks talk alot about. As you say, the paths dig into the roots, but it still requires work off cushion to push the state changes into your life. None of that is showing up in the academic literature yet, since, as Derek2 mentioned in his response, studies aren't far enough along. I suspect they really don't quite know how to ask the right questions.

Still, it's tough to decide what to tell someone coming to meditation cold and looking for relief, what they should do. They've probably seen the popular literature on mindfulness and are looking for a quick solution. To tell them it will take ten years of experimenting with what works and what doesn't, and really becoming mindful of their reactions on a daily basis which a consistent daily practice will enable, and, yes, maybe even in the end they will need to take medication so they can maintain the kind of objective, nonjudgemental awareness needed for mindfulness, it sounds kind of daunting. People differ, and for some it will naturally go more quickly than for others. You want to be encouraging but not give a false impression.

RE: Meditation and Depression
Answer
8/20/17 10:34 PM as a reply to svmonk.
My understanding of the literature is that Mindfulness Based Cognitive Therapy is indicated for people with Major Depressive Disorder (MDD) who are not presently experiencing a Major Depressive Episode. This is what is recommended in the UK's National Institue of Clinical Excellence (NICE) guidelines: https://www.nice.org.uk/guidance/cg90/chapter/1-guidance. There is a caveat, it only appears to be effective in people with at least three prior episodes. 

Though for that population it appears to be very effective in reducing relapse: https://www.bangor.ac.uk/mindfulness/nhs.php.en

I can't recall the papers at the moment, but I've heard that MBCT wasn't effective in people who were presently experiencing a depressive episode. I also have heard that it can actually exacerbate symptoms. Though I'm hestitant saying this without a citation in mind. I do recall Tucker Peck mentioning the later point, though, even though he uses a lot of mindfulness in his practice as a psychologist. This makes a kind of intuitive sense. If someone is very, very depressed and starts meditating, at the beginning they may just become more familiar with the fact that they're depressed. 

However, MBCT is a specific protocol. It would likely be considered very "lite" by people here. I'm less familiar on the research with different types of meditation. The anecdotal evidence here seems to suggest that meditation helps people with their depression, but it takes a very long time. I think of Kenneth Folk humbly accepting antidepressants at third path, though not getting depressed after fourth. 

The other thing about antidepressants is that some meta-analyses have found that they only reliably work better than placebo for people with more severe depression. They don't seem to work as well for people with mild-moderate depression. That being said, the placebo effect for them is quite powerful, likely due to socio-cultural reason, as well as the presence of side effects (placebos that give side effects actually work better!). 

Also, the fact that things that work tend to work equally well is a pattern we see a lot. It's something that I've always found quite curious. I'm very interested in how we may be able to combine or target things to get better outcomes. Unfortunately this doesn't get a lot of research attention, as most of it is directed at finding if approaches work, full stop; and after that comparing different approaches for the same problem.

There is a very early, but intersting, study looking at combining exercise and meditation together: http://www.nature.com/tp/journal/v6/n2/full/tp2015225a.html?foxtrotcallback=true

I would typically be careful of generalising studies that look at healthy participants levels of depression to people with MDD. 

It is interesting that mindfulness and 'attention training' is becoming a gold-standard intervention in CBT though. Although in this context, it's part of the cognitive model and just a part of a suite of interventions. It's used to help people detach from and postpone worries in Generalised Anxiety Disorder, as well as to help people externalise attention in Social Anxiety Disorder. As rumination, which is (thoeretically) mainly found in depression, and worry, which is mainly found in GAD, are seen as similar cognitive processes, it makes sense that mindfulnes based inteventions targeting rumination may be useful in depressive disorders. People on this board might be interested in Metacognitive Therapy (MCT), Acceptance and Commitment Therapy (ACT) and Dialetic Behaviour Therapy (DBT), which are all newer approaches for treating psychological disorders, with a large mindfulness and attention training component. 

Personally, I think most people with MDD will be better of with 12 sessions of CBT; then if they have recurrent depression to do MBCT when they're well. I encourage all of my clients to exercise: if we could put exercise effects in a pill it would be hailed as a miracle cure. Though, I don't dissuade anyone from meditating who is interested in it. 

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PS: I always enjoy your writings SVMonk emoticon