'Sacred' Word Repetition May Improve PTSD Symptoms, Insomnia

Batya Swift Yasgur, MA, LSW

June 29, 2018

Mindful repetition of a mantram, a sacred word, effectively reduces symptoms of combat-related posttraumatic stress disorder (PTSD) and insomnia, results of a randomized controlled trial show.

Investigators compared mantram repetition to present-centered therapy in veterans with PTSD. Both interventions were offered weekly for a total of 8 weeks.

Although both groups experienced some improvement in PTSD symptoms and insomnia, those in the mantram group had significantly greater improvements in both PTSD and insomnia. Benefits continued to be present at 2-month follow-up.

"The mantram program could certainly be an adjunct to other therapies for PTSD and would be an excellent 'precursor' to other therapies because of its simplicity and convenience," lead author Jill E. Bornmann, PhD, RN, research scientist, VA San Diego Healthcare System, and clinical professor, University of San Diego Hahn School of Nursing, California, told Medscape Medical News.

"For people who do not like other therapies, such as mindfulness or CBT, mantram is a good substitute," she said.

The study was published online June 20 in the American Journal of Psychiatry.

Daily Fear, Anxiety

PTSD affects up to 20% of US troops returning from Iraq and Afghanistan and an estimated 30% of Vietnam-era veterans, the authors write.

Several nonpharmacologic therapies have been shown to be effective in military-related PTSD, but many veterans retain clinically significant symptoms at posttreatment assessment.

Previous trials of other complementary therapies for PTSD have been limited by small sample size or a lack of active controls.

The mantram repetition program "has been found to mitigate PTSD symptoms and other psychological distress and to improve quality of life in a variety of populations," the authors state.

The program "teaches people to intentionally slow down thoughts and practice 'one-pointed attention' by silently repeating a personalized (self-selected) mantram, a word or phrase with spiritual meaning."

"I had been teaching passage meditation, as developed by Eknath Easwaran, a spiritual meditation teacher, and taught at the Blue Mountain Center of Meditation, to people living with HIV/AIDS," Bormann recounted.

"Although most students were unable to sustain daily meditation practice, they continued using a mantram for insomnia while awaiting lab tests and to help them cope with daily fear and anxiety, and they loved it," Bormann recounted.

Bormann began to study the impact of these teachings on health outcomes in veterans with HIV and other chronic diseases. One veteran reported improvements in posttraumatic dreams.

"After that, I started studying the effects of mantram, slowing down, and one-pointed attention in veterans with PTSD," she reported.

First RCT

Bormann described the current study as "the first randomized controlled trial comparing mantram therapy to present-centered therapy, which is an evidence-based problem-solving, nontrauma-focused treatment for PTSD."

Self-selected treatment-seeking Veterans Health Administration patients (n = 173; age ≥18 years) were randomly assigned to either the mantram group (n = 89) or the present-centered therapy comparison group (n = 84). Both groups received their respective interventions individually in eight weekly 1-hour sessions.

The study used open allocation (ie, participants were informed of assignment at randomization) but blinded assessment before treatment, after treatment (week 9), and at 2-month follow-up (week 17).

All participants had had one or more traumatic experiences related to military service, all met DSM-IV-TR criteria for PTSD, and all met severity cutoff scores on the Clinician-Administered PTSD Scale (CAPS) and the PTSD Checklist–Military.

Participants taking medications were instructed to continue their regimen but were asked to refrain from receiving other psychotherapy or complementary therapy during the study.

Individuals with severe suicidal ideation, schizophrenia spectrum disorders, untreated bipolar disorder, cognitive impairment, or active substance abuse were excluded.

The primary outcome measure was reduction of ≥10 points on the CAPS, which is considered a "clinically meaningful improvement."

Secondary outcomes included reduction in insomnia (as measured by the seven-item Insomnia Severity Index), depression (as measured by the Patient Health Questionnaire–9), and anger (as measured by the State-Trait Anger Inventory–Short Form).

Additional secondary outcomes included spiritual well-being, mindfulness, and quality of life.

Broad Applicability

There were no significant differences found between the two groups at baseline with respect to demographic characteristics, medication use, or expectations concerning the treatment.

Attendance at the sessions was similar between the two groups, with mantram participants attending an average of 7.80 sessions and present-centered therapy participants attending 7.75 sessions.

Compared to the present-therapy group, the mantram group showed significantly greater improvements in CAPS score, both at the posttreatment assessment (between-group difference across time, -9.98; 95% confidence interval [CI], -3.63 to -16.00; P = .04; d = 0.49) and at the 2-month follow-up (between-group difference, -9.34; 95% CI, -1.50 to -17.18; P = .04; d = 0.46).

Although patients in the mantram group self-reported a lower degree of PTSD symptom severity at the posttreatment assessment, there was no difference between the groups at the 2-month follow-up.

Compared to the present-therapy group, however, significantly more participants in the mantram group who completed the 2-month follow-up no longer met criteria for PTSD (40% vs 59%; χ2 = 4.55; P < .04).

Nevertheless, the percentages of those in the mantram group and those in the present-centered therapy group who experienced clinically meaningful changes on the CAPS score did not differ significantly (75% vs 61%, respectively).

Reductions in insomnia were significantly greater for participants in the mantram group at posttreatment assessment (false discovery rate–adjusted P < .05; Cohen's d = 0.59) and 2-month follow-up (false discovery rate–adjusted P < .001; d = 0.69).

There were no significant between-group differences in any remaining outcome measures.

"I was not surprised by the findings, but I was surprised that we did not find improvements between study arms in more of the secondary outcomes, such as anger and spiritual well-being," Bormann commented.

The comparison arm of patient-centered therapy "is a very strong control condition that is now considered an evidence-based practice, which might explain this," she added.

She noted that the findings can be applied to other traumatized populations, as well as other individuals undergoing stressful conditions, including family caregivers, homeless women, and healthcare providers.

Compelling Study

Commenting on the study for Medscape Medical News, Philip Muskin, MD, DFLAPA, professor of psychiatry, Columbia University Medical Center, New York City, and secretary of the American Psychiatric Association, who was not involved with the study, called it a "very compelling study, overall."

The study provides "another piece of what you can offer a patient with trauma. The bottom line is that mantram meditation clearly helped people, but is it better?" he said.

"It's somewhat better, although the problem-solving therapy is longer than what they did in the study, so to some extent it's a little unfair to compare because the protocol is different," Muskin added, who is a contributing author and coeditor of Complementary and Integrative Treatment in Psychiatry (American Psychiatric Publishing, 2017).

He described mantram repetition as "essentially a meditative therapy that has tremendously beneficial effects from the mind to be brain, because if you can quiet your mind, you can quiet your brain."

Bormann added, "A take-home message is to be open-minded and not judge this intervention before you have tried it for yourselves."

The authors note that "further assessment of mantram therapy in trials and real-world settings is clearly desirable, especially because mantram therapy may appeal to some veterans who may prefer therapies that are not trauma-focused, that include some element of spirituality, or that reduce sleep disturbances."

The study was supported by Clinical Services Research and Development, Office of Research and Development, Department of Veterans Affairs. It was conducted with resources from the Center of Excellence for Stress and Mental Health, the VA San Diego Healthcare System, and the Edith Nourse Rogers Memorial Veterans Hospital and Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts. The study authors and Dr Muskin have disclosed no relevant financial relationships.

Am J Psychiatry. Published online June 29, 2018. Abstract

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