Transcendental Meditation and Hypertension
Transcendental Meditation and Hypertension
June 2001; Volume 4; 61-65
By Alan D. Forker, MD, FACC
Maharishi Mahesh Yogi introduced transcendental meditation (TM) to the Western world about 40 years ago. Derived from the Vedic tradition of India,1 TM is described as a transcendental consciousness, a fourth state (vs. awake, asleep, and dreaming), a silent state of awareness, or restful relaxed alertness. Since TM’s introduction, it has been estimated that more than five million TM practitioners worldwide use its standardized form.2
Mind/body medicine practice and research have utilized three main types of meditation: TM; relaxation response, modeled after TM by Herb Benson, MD, of Harvard University; and mindfulness meditation, rooted in ancient Buddhist spiritual practices and introduced by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical School.2 Unfortunately for the average reader/explorer, the best technique for health care outcomes is difficult to determine from the literature. However, in systemic hypertension, recent work favors TM.
Mechanism of Action
TM’s exact mechanism of action still is being investigated, but the model of psychological or mind/body influence is thought to be through the sympathetic nervous system.3 TM seems to produce a parasympathetic or vagal dominance with hypometabolism, characterized by decreases in oxygen consumption, heart rate, blood pressure (BP), respiratory rate, and muscle tension.
EEG studies of TM have reported increased slow alpha-wave activity with high-voltage theta-wave bursts.4 In addition, increased phase coherence, or "synchrony," has been reported. This is a measure of the degree to which the EEG amplitudes from different scalp locations are similar. TM can be thought of as inducing a wakeful, hypometabolic, integrated conscious response.
Clinical Research Evidence
The data can be divided into the pre-Eisenberg (1993) and post-Schneider era (1989).
Pre-Eisenberg Era. Five groups of researchers evaluated and summarized the earlier studies,5-9 which showed a decrease in systolic blood pressure (SBP) of 6-15 mm Hg and a decrease in diastolic blood pressure (DBP) of 0-6 mm Hg. But these studies suffered from many problems including: lack of adequate controls; return to pre-TM BP levels when TM was discontinued; lack of long-term follow-up effect; and inadequate baseline demographic data (still a problem with recent studies), especially target organ damage, high- vs. low-risk indicators, and family history.5 Also, TM frequently is not separated from other behavioral and meditation techniques. In fact, two study summaries have no specific TM data.7,9
Eisenberg Analysis. Eisenberg et al screened MEDLINE from 1970 to 1991 and found 857 articles regarding behavioral techniques in hypertension; 26 were selected as adequate studies, even though technical quality was below average.9 The study group (1,264 patients: treatment 723, control 541) had an average BP of 145/93 mm Hg, averaged 49 years of age, and was 65% male. The subjects were categorized into five treatment groups: biofeedback (n = 90), meditation (n = 21), relaxation (n = 278), stress management (n = 50), or a combination (n = 284). Only six studies had a credible sham or placebo intervention. When treatment minus sham blood pressures were calculated, SBP decreased 6.6 mm Hg and DBP decreased 4.5 mm Hg on day 1. However, after day 1, SBP decreased 2.8 mm Hg and DBP decreased 1.3 mm Hg. No single intervention was superior, but again, specific TM data are lacking.
Based on these analyses, in 1997, The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) concluded that the available literature did not support the use of relaxation therapies for definitive treatment or prevention of hypertension. This conclusion continued into the year 2000, with publication of the textbook, Hypertension: A Companion to Brenner & Rector’s The Kidney, by Oparil and Weber, and the Core Curriculum for Clinical Hypertension by the American Society of Hypertension. None of the current expert opinions/consensus statements include any references from the Schneider group, data from which follows.
Schneider Era. In the first key publication in the Schneider era, Alexander et al compared TM (n = 20), mindfulness training (n = 21), mental relaxation (n = 21), and no treatment (n = 11) in a three-month study of 73 nursing home residents, average age 80.7 years.10 Six baseline cognitive function tests were obtained; TM results were best for improved cognitive function. SBPs at three months were: TM 125.4 mm Hg (P < 0.01), mindfulness 130.3 mm Hg, and relaxation 145 mm Hg vs. 135 mm Hg for no treatment. No baseline BPs or demographics were provided.
Survival rates after 36 months were 100% for TM (P < 0.00025), 87.5% for mindfulness, and 65% for relaxation vs. 77.3% for no treatment. Quality of life scores clearly favored TM (more relaxed, less boredom, felt younger and better overall). This is an ideal population for future studies, as the elderly grapple with physical decline and death. A 15-year follow-up is available for these 73 subjects.11 Mean survival time for all cause mortality was 9.17 years for TM vs. 7.48 years for all other groups combined (P < 0.04). Cardiovascular mortality figures were similar: 11.4 years for TM vs. 9.91 years for others (P < 0.05).
Schneider et al randomized 127 older African-Americans (mean age 67 years, mean baseline BP 147/92 mm Hg) to three months of comparative treatment: TM (n = 36), progressive muscle relaxation (n = 37), or an educational risk factor reduction control group (n = 38).12 Only 111 completed the three-month study. Again, no data were provided regarding etiology, duration, family history, or target organ damage.
When adjusted for age and baseline BP, TM provided the best results. (See Table 1.) In this single-blind study, TM resulted in a decrease in clinic BP of 11/6 mm Hg, which is similar to the results of drug treatment trials. The effect of TM in African-American females (-13.4/-6.6 mm Hg) was greater than that observed in African-American males (-7.9/-4.3 mm Hg), but the females were older and heavier, and had higher baseline SBP (150 mm Hg vs. 143.5 mm Hg).13
| Table 1 | |||
| Blood pressure reduction | |||
| TM | PMR | EC | |
| SBP | -10.9 ± 2.1 | -4.9 ± 2.1 | -0.2 ± 2.0 |
| DBP | -5.6 ± 1.1 | -2.5 ± 1.1 | +0.8 ± 1.6 |
| Differences between groups | |||
| TM - EC | PMR - EC | TM - PMR | |
| SBP | -10.7 ± 2.93 | -4.7 ± 2.9 | -6.0 ± 3.02 |
| DBP | -6.4 ± 1.64 | -3.3 ± 1.62 | -3.1 ± 1.61 |
| SBP = systolic blood pressure DBP = diastolic blood pressure TM = transcendental meditation PMR = progressive muscle relaxation EC = educational risk factor control group |
|||
| 1P < 0.05, 2P < 0.025, 3P < 0.0005, 4P < 0.00005 | |||
| Adapted from: Schneider RH, et al. A randomized controlled trial of stress reduction for hypertension in older African-Americans. Hypertension 1995;26:820-827. | |||
Comparative Summary of Meditation Techniques
Orme-Johnson and Walton published a recent qualitative review of 175 studies comparing stress reduction techniques.14 In addition, other researchers have published quantitative meta-analyses of studies of hypertension (n = 26), anxiety (n = 146),15 overall mental health (n = 42),16 and substance abuse (n = 198).17 TM provided the best results in each group.
Procedure for TM
The introductory TM training course is taught in seven steps, usually over four to five days, and costs $1,200. The training includes small group and/or private instruction and the introduction of one’s mantra, a word that helps the practitioner release the past and establish awareness of the present.
Ideally, TM is done in a quiet area. The practitioner sits comfortably with his eyes closed and obtains relaxed awareness by focusing on the mantra. This focus allows the practitioner to let go of surface chatter or stimuli, and listen to his or her inner voice or true self. Twice daily meditation for 20 minutes is recommended. For additional information or to locate a training center, contact the Maharishi Vedic Education Development Corp. at www.tm.org.
Cost Analysis of TM
Some preliminary data are available for health care utilization and cost-effectiveness of TM.18,19 Orme-Johnson reported a decrease of 87% in heart disease-related hospital admissions among 2,000 TM practitioners.18 Herron et al created a projected, simulated cost analysis (not actual cost analysis) over 20 years of patients ages 35-64 years without coronary artery disease.19 They compared hydrochlorothiazide, propranolol, nifedipine, prazosin, and captopril to TM (utilizing only the initial course fee of $1,200 for TM cost). Average treatment cost per year for TM was $286 vs. $375 for hydrochlorothiazide, $937 for captopril, and $1,051 for propranolol. A mild reduction in BP from the practice of TM was estimated to be comparable to the effect of the drugs.
Conclusion
Although the literature reveals only a handful of high-quality, randomized controlled trials in TM, other factors should be mentioned: There is impressive anecdotal evidence for TM; TM lacks side effects; and TM probably is cost-effective.
TM is one of the meditation/behavior modification choices supported by an increasing database of literature. However, more data are needed to determine which mind/body technique is best and most cost-effective. The Schneider-era data are provocative and favorable for TM at this point.
Recommendation
I recommend TM for labile borderline or mild sustained hypertension. TM is a reasonable approach in a motivated patient who can afford the initial $1,200 cost. I encourage patients to combine TM with other lifestyle modifications, especially smoking cessation, weight loss, exercise, social support, and faith/prayer (for the appropriate patient), as in the Ornish program for coronary artery disease reversal.
As an adjunct to medical treatment for moderate-to-severe hypertension, I would consider TM in the right patient. How do you identify that patient? Not by laboratory acute reactivity testing,6 but by listening to the patient and observing psychological distress,20 especially anxiety and depression.3 Such a patient may benefit most from a six-month TM trial.
Dr. Forker is Professor of Medicine, University of Missouri-Kansas City School of Medicine and Clinician-Educator at Mid America Heart Institute of St. Luke’s Hospital in Kansas City.
References
1. Maharishi Mahesh Yogi. On the Bhagavad Gita—A New Translation and Commentary. Harmondsworth, England: Penguin; 1969.
2. Borrowes A. Meditation and implications for clinical practice. Integrative Med Consult 2001;3:6-7.
3. Rozanski A, et al. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999;99:2192-2217.
4. Jevning R, et al. The physiology of meditation: A review. A wakeful hypometabolic integrated response. Neurosci Biobehav Rev 1992;16:415-424.
5. Frumkin K, et al. Nonpharmacologic control of essential hypertension in man: A critical review of the experimental literature. Psychosom Med 1978;40: 294-320.
6. Pickering T, Gerin W. Cardiovascular reactivity in the laboratory and the role of behavioral factors in hypertension: A critical review. Ann Behav Med 1990;12: 3-16.
7. Jacob RG, et al. Relaxation therapy for hypertension: Design effects and treatment effects. Ann Behav Med 1991;13:5-17.
8. Hunyor SN, Henderson RJ. The role of stress management in blood pressure control: Why the promissory note has failed to deliver. J Hypertens 1996;14: 413-418.
9. Eisenberg DM, et al. Cognitive behavioral techniques for hypertension: Are they effective? Ann Intern Med 1993;118:964-972.
10. Alexander CN, et al. Transcendental meditation, mindfulness, and longevity: An experimental study with the elderly. J Pers Soc Psychol 1989;57:950-964.
11. Alexander C, et al. A randomized controlled trial of stress reduction on cardiovascular and all cause mortality in the elderly: Results of 8 and 15 year follow-up [abstract]. Circulation 1996;93:629.
12. Schneider RH, et al. A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension 1995;26:820-827.
13. Alexander CN, et al. Trial of stress reduction for hypertension in older African Americans. II. Sex and risk subgroup analysis. Hypertension 1996;28:228-237.
14. Orme-Johnson DW, Walton KG. All approaches to preventing or reversing effects of stress are not the same. Am J Health Promot 1998:12:297-299.
15. Eppley KR, et al. Differential effects of relaxation techniques on trait anxiety: A meta-analysis. J Clin Psychol 1989;45:957-974.
16. Alexander CN, et al. Transcendental meditation, self-actualization and psychological health: A conceptual overview and statistical meta-analysis. J Soc Behav Pers 1991;6:189-247.
17. Alexander CN, et al. Treating and preventing alcohol, nicotine, and drug abuse through transcendental meditation: A review and statistical meta-analysis. Alcohol Treatment Q 1994;11:13-87.
18. Orme-Johnson D. Medical care utilization and the transcendental meditation program. Psychosom Med 1987;49:493-507.
19. Herron RE, et al. Cost-effective hypertension management: Comparison of drug therapies with an alternative program. Am J Man Care 1996;2:427-437.
20. Mann SJ. The mind/body link in essential hypertension: Time for a new paradigm. Altern Ther Health Med 2000;6:39-45.
June 2001; Volume 4; 61-65
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.