Meditation Helps Sleep Disturbance, Cuts Fatigue, Depression

Pauline Anderson

February 19, 2015

Older adults who follow a mindful meditation program have improved sleep quality as well as less daytime fatigue and depression compared with their counterparts who take part in a sleep hygiene education (SHE) program, new research shows.

Investigators at Keck School of Medicine, University of Southern California, Los Angeles, found that the mindfulness program, which is available to the general community, resulted in improved sleep "relative to a highly active and standardized sleep hygiene education program."

"This is the first clinical trial to date to examine the effect of mindfulness meditation on moderate sleep disturbances in older adults," lead author David S. Black, PhD, assistant professor of preventive medicine and director of the American Mindfulness Research Association, told Medscape Medical News.

The study was published online February 16 in JAMA Internal Medicine.

Cultivating Positive Emotions

The study included 49 adults aged 55 years and older with no cognitive impairment or depression who experienced sleep disturbance, as indicated by a score of greater than 5 on the Pittsburgh Sleep Quality Index (PSQI), a widely used and validated self-report questionnaire. Patients with sleep apnea and restless legs syndrome were excluded from the study.

The mean age of participants was 66.3 years, and 67% were women. The mean PSQI was 10.2.

Patients were randomly assigned to receive either a mindfulness awareness practices (MAPs) intervention (n = 24) or the SHE program (n = 25).

The MAPs program is a weekly 2-hour, 6-session, group-based course available in person or online. Group members engage in a mean of 10 to 30 minutes of mindful experiential practice in each class in addition to group discussion and mindfulness practice homework.

Participants practiced mindful sitting meditation, mindful eating, mindful walking, and mindful movement. They learned to cultivate their natural capacity for attention, awareness, stillness, and empathy.

"These simple yet challenging meditation practices provide the opportunity for people to expand their nonjudgmental awareness of sensory experiences arising in each moment," said Dr Black. "Practices also allow for the cultivation of positive emotions that can counterbalance negative thinking patterns."

The SHE program is a weekly 2-hour, 6-session, group-based course in sleep hygiene and education. It also includes in-class group discussion and homework that involves practicing sleep hygiene strategies, including avoidance of noise, bright lights, and the drinking of caffeine before bed.

The mean session attendance was similar across both groups.

The study showed that on the basis of scores on the Five Facet Mindfulness Questionnaire, the mean level of mindfulness significantly increased in the MAPs group but did not change in the SHE group.

The between-group mean difference was 0.2 (95% confidence interval [CI], 0.1 - 0.3) with an effect size of 0.76 (P = .008), showing that mindfulness levels changed only in the MAPs group, as intended.

The PSQI improved by a mean of 2.8 in the MAPs group and by a mean of 1.1 in the SHE group, indicating greater improvement in the MAPs group (between-group mean difference, 1.8; 95% CI, 0.6 - 2.9).

Large Effect Size

The effect size of 0.89 for improvement in sleep quality "was large and of clinical relevance" considering that other studies have shown the effect sizes of behavioral interventions on self- reported sleep quality outcomes averaged 0.76 among older adults, the authors noted.

They noted that previous research has shown that in adults with insomnia, the mean effect sizes were 0.87 for pharmacotherapy, such as benzodiazepines, and 0.96 for cognitive-behavioral therapy (CBT).

The current study also showed improvements in sleep-related daytime impairment. Compared with the SHE group, those in the MAPs group had significant improvements in fatigue, as measured by the Fatigue Inventory–Severity, and depression, as measured by the Beck Depression Inventory II.

Although it is possible that it was these improvements that led to better sleep, not the mindfulness program, "it seems somewhat backwards thinking conceptually," said Dr Black.

Mindfulness meditation may improve sleep by settling the brain's arousal systems when attempting to sleep, and helps individuals take a nonjudgmental approach to thinking that "counters worry about sleep," he added.

Although mindfulness programs are available online and anyone can learn the techniques, our current fast-paced culture "is not very supportive of these qualities and can actually function to dull these capacities," said Dr Black.

The findings might be applicable to younger patients with moderate sleep complaints as well as older ones, he added. But those with severe sleep problems, including clinical insomnia, typically require intensive assessment and treatment. Mindfulness meditation could be integrated with evidence-supported programs such as CBT for patients with these more severe sleep problems, he said.

Although this study only looked at short-term benefits, previous research that examined the effects of mindfulness practice on stress-related ailments found that the benefits might persist as long as people continue mindful meditation. Some studies have recorded benefits lasting for 1 year, said Dr Black.

Impressive Findings

In an accompanying editorial, Adam Spira, PhD, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, commented that using a PSQI score rather than an insomnia diagnosis to identify poor sleepers "makes sense," given that research shows that older adults with a PSQI greater than 5 have adverse health outcomes, such as frailty and lower cognitive function.

He noted that a PSQI of greater than 5 can also reflect severe disturbances, so the study likely included some patients with clinical insomnia. And because restless legs syndrome was self- reported, the study may also have included patients with this disorder.

"The likelihood that their sample contained individuals with sleep disturbances other than insomnia and that their sleep may have been more than moderately disturbed makes the authors' positive findings all the more impressive," wrote Dr Spira.

The study raises some questions that need to be answered in future research, he said. Such questions include which aspects of sleep quality mindful meditation improves, and how this intervention affects the different PSQI components, including sleep quality, latency, duration, and efficiency.

In addition to mindful meditation, other approaches are needed to improve or prevent insomnia in older people, he said. "Indeed, a menu of appealing options is necessary to compete with the quicker fix offered by the various sleep medications available to older adults."

He called for future studies of mindful meditation on sleep improvement in older adults with restricted mobility. And he recommended more research into volunteerism ― "especially intensive and physically, cognitively and socially engaging volunteering."

Dr Black and Dr Spira report no relevant financial relationships.

JAMA Intern Med. Published online February 16, 2015. Abstract, Editorial


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