Meditation May Best Gold Standard Therapy for PTSD

Batya Swift Yasgur, MA, LSW

November 19, 2018

Transcendental meditation (TM) is effective in reducing symptoms of post-traumatic stress disorder (PTSD) in veterans and may be a helpful alternative for those who prefer not to receive or do not respond to traditional trauma-focused prolonged exposure (PE) therapy, new research suggests.

Investigators randomized 200 veterans with PTSD resulting from active military service to receive 12 sessions of TM, PE, or PTSD health education (HE) over a 12-week period, with daily home practice.

They found more significant reductions in PTSD scores on the Clinician-Administered PTSD Scale (CAPS) in both the TM and PE groups versus the HE group.

Moreover, over half of those receiving TM and close to half of those receiving PE showed clinically significant improvement, compared with only a third of those receiving HE.

"What we wanted to find out from our study is whether a nontrauma-focused treatment such as TM could be as effective as PE, which is the gold standard therapy already being offered in the VA for PTSD," lead author Sanford Nidich, EdD, director, Center for Social-Emotional Health and Consciousness and professor of physiology and education, Maharishi University of Management, Fairfield, Iowa, told Medscape Medical News.

"We evaluated TM as a stand-alone therapy and found that it was indeed effective and, quite possibly, could also be applied as an adjunctive treatment with other therapies," he said.

The study was published online November 15 in Lancet Psychiatry.

"Effortless Process"

"PTSD is an extremely serious and disabling condition that affects as many as 14% of US veterans deployed in or returning from combat in Afghanistan and Iraq," Nidich said.

PE is a "trauma-focused behavioral treatment for PTSD involving a graduated exposure to imaginal and in vivo aspects of trauma-related experiences," the authors write.

However, the approach is not always helpful for veterans with PTSD, Nidich noted.

"There are so many veterans now returning from service either with medically documented PTSD or PTSD symptoms that need attention and, in most cases, treatment, but it's clear that even the best therapies are only helping a minority of patients," he said.

"So there's a very urgent need to look at other possible treatments for PTSD, especially treatments that veterans do not immediately see as necessitating them to focus directly on their trauma event," he added.

TM is practiced for about 20 minutes twice a day and involves using a mantra (sound) "without concentration or contemplation," the authors note

"TM is a totally effortless process, allowing the individual to effortlessly and spontaneously attain a quieter, less excited state of mental activity within their own mind," Nidich said.

The authors note that TM differs from mindfulness practice, which "involves focusing on the present moment in a specifically recommended way whereas TM involves the effortless thinking of a mantra (sound), without concentration or contemplation, to produce a settled and progressively lesser excited psychophysiological state of so-called restful alertness."

He noted that several preliminary studies on TM and PTSD were limited by small sizes and methodological issues.

"The next step, in terms of quality research on vets with PTSD, was to compare TM directly with the gold standard of treatment being offered at VAs around the country — namely PE."

Beyond comparing TM to PE, "we wanted to compare it to a third group, which served as a control — namely, PTSD health education focusing on the benefits of a healthy lifestyle including diet, physical activity, and sleep hygiene, for coping with PTSD," he said.

Multiple Trauma Types

To investigate the question, the researchers studied veterans with PTSD who were required to have a CAPS score of ≥ 45, PTSD symptoms resulting from an event experienced during active military service, and ≥ 3 months since the service-related traumatic event.

Participants taking medication were required to be on a stable regimen for ≥ 2 months prior to enrollment and were excluded if they had psychosis, mania, bipolar disorder, cognitive impairment, or were suicidal or homicidal.

The primary outcome was change in PTSD symptom severity over a 3-month period, as assessed by the CAPS-IV, which was administered at baseline and 3-months post-test.

A decrease of ≥ 10 points was considered to be a "minimal standard" for clinically significant improvement in PTSD symptoms.

Secondary outcomes included self-reported PTSD symptoms using the PTSD Checklist–Military Version (PCL-M) and depression, assessed by the Patient Health Questionnaire 9 (PHQ-9).

Of the 814 veterans assessed for eligibility, 203 were randomly assigned to receive intervention with TM (n = 68, 56% men, mean [SD] age 46.4 [14.3] years, 30% black, 56% white, 12% Hispanic), PE (n = 68, 82% men, mean age 48.5 [15.6] years, 21% black, 63% white, 31% Hispanic), or HE (n = 67, 85% men, mean age 46.2 [16.4] years, 27% black, 24% Hispanic).

Close to half (49%, 52%, and 53%, respectively) had been in combat duty, and most (82%, 85%, and 86%, respectively) had experienced combat exposure.

Roughly three quarters had experienced combat-related trauma, between one quarter and one third had experienced sexual trauma, and most had experienced disaster exposure (88%, 88%, and 91% respectively) as well as a serious injury event (81%, 96%, and 93% respectively).

Close to 100% had experienced "other" trauma.

Feasible, Effective

The mean CAPS total score at baseline was 79.7 (17.8) and 68% of participants were taking one or more medications prescribed for PTSD.

After adjustment for baseline measures, number of PTSD medications, sex, and number of years since military discharge, TM was found to be significantly noninferior to PE on change in CAPS score from baseline to 3-month post-test (difference between groups in mean change, –5.9; 95% CI, –14.3 to 2.4; P = .0002).

TM proved to be significantly superior to HE, with significant reductions in CAPS score of –14.6 (95% CI, –23.3 to –5.9; P = .0009). PE was likewise found to be superior to HE (–8.7; 95% CI, –17.0 to –0.32; P = .041).

Clinically significant improvements on the CAPS score were found in 61% of those receiving TM, 42% of those receiving PE, and 32% of those receiving HE.

The effect sizes for PTSD symptoms measured by CAPS and PCL-M and depression measured by PHQ-9 ranged from 0.90 to 1.2 for TM, from 0.63 to 0.89 for PE; and from 0.14 to 0.34 for HE.

The researchers found similar results when they included additional covariates: antidepressants and antipsychotic medications at baseline; change in number of PTSD medications; baseline social support; number of treatment sessions attended; or baseline outcome measures.

"Our findings point to the feasibility and efficacy of TM as an intervention for veterans with PTSD," Nidich said.

High Attendance, Satisfaction

The mean attendance of treatment sessions in the TM group was 75% (35%), and attendance in the PE and HE groups  was 68% (31%) and 65% (30%), respectively. However, these differences were not deemed to be significant.

The treatment dropout rate was highest for PE, followed by HE and TM.

"It also has documented other effects, including reduction in cardiovascular disease and blood pressure," he added.

The authors include two accounts of study participants. One reported difficulties with sleep, recurring thoughts of regret, and feeling he would be "better off dead." He described previous counseling as a "waste of time" and pharmacotherapy as causing "terrible side effects."

Following the TM intervention, he reported "nothing but good experiences with this method," including sleeping through the night, clearer thinking, and reduced stress.

A second veteran diagnosed with military and sexual trauma described her practice as "easy," "peaceful," and "pleasant," and reported healing from nightmares, learning to drive, starting college, and finding a job.

Compelling Evidence

Commenting on the study for Medscape Medical News, Vernon A. Barnes, PhD, assistant professor emeritus, Department of Pediatrics, Augusta University, Georgia, who was not involved with the study, said the "new findings provide compelling evidence for TM as a first-line nonpharmacologic PTSD treatment for which benefits could be immediately translated into improved care in military medicine, and which could have a substantial effect on military health if widely disseminated."

Barnes, author of an accompanying editorial, continued: "Implementation of TM training at military medical facilities could have a substantial effect on health as an adjunct to the standard of care and there is promise of considerable value to improve the quality of life for military service members."

Barnes noted that TM "is not a religion or a philosophy, requires no change in belief or lifestyle, and is compatible with any and all medical recommendations."

Nidich said that his group has researched TM not only in veterans but also in prison populations and "saw immediate and very dramatic improvements in the mental health of inmates over just a few months of practice, in terms of reduced trauma symptom severity and depression."

Participants described "an inner sense of peacefulness and freedom they hadn't experienced before, even though they were in the most restrictive of situations as prison inmates," Nidich reported.

He added, "the [incident of the] veteran with PTSD who carried out a mass shooting in a bar a few weeks ago reminds us of the urgency of addressing PTSD in this population."

The study was supported by the Department of Defense, US Army Medical Research. The authors have reported no relevant financial relationships.

Lancet Psychiatry. Published online November 15, 2018. Abstract, Editorial

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