Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial

Abstract

Mindfulness-based interventions may be acceptable to veterans who have poor adherence to existing evidence-based treatments for posttraumatic stress disorder (PTSD).
To compare mindfulness-based stress reduction with present-centered group therapy for treatment of PTSD.
Randomized clinical trial of 116 veterans with PTSD recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December 2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Data collection was completed on April 22, 2014.
Participants were randomly assigned to receive mindfulness-based stress reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a daylong retreat) focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current life problems.
The primary outcome, change in PTSD symptom severity over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater severity; reduction of 10 or more considered a minimal clinically important difference) at baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and symptom severity assessed by independent evaluators using the Clinician-Administered PTSD Scale along with improvements in depressive symptoms, quality of life, and mindfulness.
Participants in the mindfulness-based stress reduction group demonstrated greater improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI, 3.34-9.53, P < .001). Although participants in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI, 2.2%-39.5%; P = .03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, -14.1% to 26.2%; P = .55).
Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect.
clinicaltrials.gov Identifier: NCT01548742.

Full text

Copyright 2015 American Medical Association. All rights reserved.
Mindfulness-Based Stress Reduction for Posttraumatic Stress
Disorder Among Veterans
A Randomized Clinical Trial
Melissa A. Polusny, PhD; Christopher R. Erbes, PhD; Paul Thuras, PhD; Amy Moran, MA; Greg J. Lamberty,PhD;
Rose C. Collins, PhD; John L. Rodman, PhD; Kelvin O. Lim, MD
IMPORTANCE Mindfulness-based interventions may be acceptable to veterans who have poor
adherence to existing evidence-based treatments for posttraumatic stress disorder (PTSD).
OBJECTIVE To compare mindfulness-based stress reduction with present-centered group
therapy for treatment of PTSD.
DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 116 veterans with PTSD
recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December
2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up.
Data collection was completed on April 22, 2014.
INTERVENTIONS Participants were randomly assigned to receive mindfulness-based stress
reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a
daylong retreat) focused on teaching patients to attend to the present moment in a
nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an
active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current
life problems.
MAIN OUTCOMES AND MEASURES The primary outcome, change in PTSD symptom severity
over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater
severity; reduction of 10 or more considered a minimal clinically important difference) at
baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and
symptom severity assessed by independent evaluators using the Clinician-Administered
PTSD Scale along with improvements in depressive symptoms, quality of life, and
mindfulness.
RESULTS Participants in the mindfulness-based stress reduction group demonstrated greater
improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD
Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy;
between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change
in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI,
3.34-9.53, P< .001). Although participants in the mindfulness-based stress reduction group
were more likely to show clinically significant improvement in self-reported PTSD symptom
severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI,
2.2%-39.5%; P= .03) at 2-month follow-up, they were no more likely to have loss of PTSD
diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, −14.1% to 26.2%; P= .55).
CONCLUSIONS AND RELEVANCE Among veterans with PTSD, mindfulness-based stress
reduction therapy, compared with present-centered group therapy, resulted in a greater
decrease in PTSD symptom severity. However, the magnitude of the average improvement
suggests a modest effect.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01548742
JAMA. 2015;314(5):456-465. doi:10.1001/jama.2015.8361
Editorial page 453
Author Video Interview and
JAMA Report Video at
jama.com
Supplemental content at
jama.com
Author Affiliations: Minneapolis
Veterans Affairs Health Care System,
Minneapolis, Minnesota
(Polusny,Erbes, Thuras, Moran,
Lamberty, Collins, Rodman,Lim);
Center for Chronic Disease Outcomes
Research, Minneapolis, Minnesota
(Polusny,Erbes); Depar tment of
Psychiatry,University of Minnesota,
Minneapolis (Polusny,Erbes, Thuras,
Lamberty, Lim).
Corresponding Author: Melissa A.
Polusny,PhD, Minneapolis VA
Medical Center (B68-2), One
Veterans Dr, Minneapolis, MN 55417
(melissa.polusny@va.gov).
Research
Original Investigation
456 (Reprinted) jama.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
Posttraumatic stress disorder (PTSD) affects 23% of
veterans returning from deployments in Afghanistan
(Operation Enduring Freedom) and Iraq (Operation Iraqi
Freedom).
1
Left untreated, it is associated with high rates of
comorbidity, disability, and poor quality of life.
2
The US De-
partment of Veterans Af-
fairs (VA) has invested
heavily in the dissemina-
tion of prolonged expo-
sure therapy and cogni-
tive processing therapy.
3
Robust evidence sup-
ports the efficacy of these
2 first-line treatments.
4
Yet 30% to 50% of veter-
ans participating in pro-
longed exposure or cogni-
tive processing therapy fail
to show clinically signifi-
cant improvements,
5,6
and
dropout is high, ranging from 30% to 38%
5-7
in randomized
trials and 32% to 44% in clinic-based studies.
8,9
A recent chart
review found that 60% of eligible Operation Enduring
Freedom/Operation Iraqi Freedom veterans failed to begin or
dropped out of these treatments.
10
Avoidance and difficul-
ties tolerating trauma-focused material likely contribute to
dropout.
7,11
Thus, research aimed at testing novel treatments
for PTSD in this population is important.
Evidence suggests that mindfulness-based stress reduc-
tion, an intervention that teaches individuals to attend to the
present moment in a nonjudgmental, accepting manner,
12
can result in reduced symptoms of depression and anxiety.
13
By encouraging acceptance of thoughts, feelings, and experi-
ences without avoidance, mindfulness-based interventions
target experiential avoidance, a key factor in the develop-
ment and maintenance of PTSD.
14
This randomized clinical
trial compared mindfulness-based stress reduction with an
active, credible intervention, present-centered group
therapy. We hypothesized that veterans randomly assigned
to mindfulness-based stress reduction would show greater
reductions in self-reported and interview-rated PTSD sever-
ity and loss of diagnosis after treatment and at 2-month
follow-up compared with those randomized to present-
centered group therapy.
Methods
Participants
Participants were veterans who met the following inclusion
criteria: (1) current full PTSD according to the Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition)
(DSM-IV)
15
or subthreshold PTSD, defined as endorsement of
DSM-IV criterion A1 and at least 1 symptom each from crite-
ria B, C, and D with significant impairment; (2) agreement to
not receive other psychotherapy for PTSD during study; and
(3) if being treated with psychoactive medications, a stable
regimen for at least 2 months prior to study entry. Exclusion
criteria were (1) current substance dependence (except nico-
tine or caffeine); (2) current psychotic disorder (eg, schizo-
phrenia, bipolar disorder); (3) prominent current suicidal or
homicidal ideation; and (4) cognitive impairment or medical
illness that could interfere with treatment.
Procedures
Patients were recruited through advertisements and clinical
referrals at a large VA medical center. All patients provided
written informed consent for participation in this study,
which was approved by the Minneapolis VA Medical Center
institutional review board. Participants completed a 5-hour
eligibility and baseline assessment that included a struc-
tured clinical interview and self-report measures. Master’s-
level assessors supervised by study authors (C.R.E. and
G.J.L.) served as independent evaluators blinded to treat-
ment condition. Posttraumatic stress disorder and Axis I psy-
chiatric disorders were assessed using structured clinical
interviews.
16,17
Outcomes were assessed before treatment, at
3-week intervals during treatment (weeks 3 and 6), after
treatment (week 9), and at 2-month follow-up (week 17).
Data collection was completed April 22, 2014.
Randomization was conducted using SAS PROC PLAN in
blocks of 4 to ensure even randomization across the length of
the study.A restricted electronic randomization chart was pro-
vided to the study coordinator by the statistician. Veterans were
randomized approximately every 2 months over a 19-month
period, for a total of 9 cohorts composed of 1 group each of the
2 conditions.
The trial protocol is available in the Supplement.
Treatment Conditions
Treatment was delivered in a group formataccording to manu-
alized protocols by 2 instructors/clinicians. For mindfulness-
based stress reduction, lead instructors completed a 9-day in-
tensive practicum training at the University of Massachusetts
Center for Mindfulness. Each lead instructor was assisted by
a doctoral-level clinician. All instructors/clinicians com-
pleted a 2-day training and received weekly or biweekly su-
pervision (by senior staff at the University of Minnesota Cen-
ter for Spirituality and Healing for mindfulness-based stress
reduction; by developer Melissa Wattenberg, PhD, for present-
centered group therapy).
Mindfulness-Based Stress Reduction
Standard protocol consists of 8 weekly 2.5-hour group ses-
sions and a daylong retreat.
12
The intervention was modified
to include an orientation to the program that incorporatedP TSD
psychoeducation and treatment rationale (session 1), fol-
lowed by 7 weekly 2.5-hour group sessions and a 6.5-hour re-
treat, for a total of 9 sessions. The program teaches partici-
pants to attend to the present moment(immediate emotional
and physical states, including discomfort) in a nonjudgmen-
tal and accepting way. Sessions include didactic training and
formal practice in 3 meditation techniques. The body scan is
a guided exercise that systematically directs attention through
various areas of the body. Sitting meditation involves devel-
oping capacity for sustained self-observation through direct-
CAPS Clinician-Administered PTSD
Scale
DSM-IV Diagnostic and Statistical
Manual of Mental Disorders [Fourth
Edition]
FFMQ Five Facet Mindfulness
Questionnaire
MCID minimal clinically important
difference
PCL PTSD Checklist
PHQ-9 Patient Health Questionnaire 9
PTSD posttraumatic stress disorder
WHOQOL-BREF World Health
Organization Quality of Life–Brief
Mindfulness-Based Stress Reduction for PTSD Among Veterans Original Investigation Research
jama.com (Reprinted) JAMA August 4,2015 Volume 314, Number 5 457
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
ing attention to specific experiences (eg, the breath, physical
sensations, thoughts, emotions, sensory stimuli). Mindful yoga
involves gentle stretches and movements practiced with
present-moment attention, which encourages greater body
awareness. Meditation techniques were taught in the same
manner as is typical in programs offered in the community,and
no modifications were made to specifically accommodate
PTSD. The daylong silent retreat provides an opportunity for
sustained practice of these techniques. Additionally, the pro-
gram encourages individuals to practice meditation tech-
niques at home and to cultivate present-moment awareness
in ordinary daily activities (eg, mindful eating and driving).
Present-Centered Group Therapy
Present-centered group therapy is an active-control condi-
tion shown to benefit individuals with PTSD.
18,19
It controls for
nonspecific therapeutic factors by providing professional con-
tact, a credible therapeutic rationale, and corresponding spe-
cific ingredients (eg, problem solving) for reducing distress,
with positive therapeutic expectancy similar to mindfulness-
based stress reduction.
13
The intervention consists of 9 weekly
1.5-hour group sessions focused on current life problems as
manifestations of PTSD.
20
Session 1 focuses on providing psy-
choeducation about PTSD and treatment rationale, building
group cohesion, and goal setting. Sessions 2 through 8 focus
on discussing daily difficulties. Session 9 focuses on review-
ing accomplishments and planning for the future. Therapists
are nondirective and encourage patients to provide each other
with support, problem solving, and validation. There was no
discussion of mindfulness meditation techniques or trau-
matic experiences.
Primary Outcome
The primary outcome, change in PTSD symptom severity
over time, was assessed using the PTSD Checklist
21
(PCL;
range, 17-85; higher scores indicate more severe symptoms)
at all assessment points (baseline and weeks 3, 6, 9, and 17).
It has excellent internal consistency (Cronbach α = 0.94-
0.97), test-retest reliability (0.96), and concurrent validity.
22
The minimal clinically important difference (MCID) for self-
reported PTSD symptom severity is a reduction of 10 or more
points on the PCL.
23
Secondary Outcomes
Diagnosis and symptom severity of PTSD were also assessed
using the Clinician-Administered PTSD Scale (CAPS)
16
before
and after treatment and at 2-month follow-up (baseline,
week 9, and week 17). Potentially traumatic events were
identified using the Life Events Checklist and further as-
sessed during interview.
24
We used the recommended1 /2scor-
ing rule, whereby a frequency score of 1 (0 = none of the time;
4 = most or all of the time) and intensity score of 2 (0 = none;
4 = extreme) is required to consider each symptom as present.
22
Diagnoses were based on DSM-IV criteria for PTSD; a severity
score was also calculated by summing frequency and inten-
sity scores for all 17 symptoms (range, 0-136; higher scores in-
dicate more severe PTSD). A reduction of 10 or more points is
considered the MCID for the CAPS.
5
Comorbid depression
symptoms were assessed using the Patient Health Question-
naire 9
25
(PHQ-9; range, 0-27;higher scores indicate more symp-
toms). The MCID for the PHQ-9 is a reduction of 5 or more
points.
26
Quality of life was assessed using the World Health
Organization Quality of Life–Brief (WHOQOL-BREF).
27
This
study reports the summed total score (range, 0-130; higher
scores indicate greater quality of life).
Mindfulness skills (observing, describing, acting with
awareness, nonjudging of inner experience, and nonreactiv-
ity to inner experience) were assessed using the Five Facet
Mindfulness Questionnaire (FFMQ)
28
at all assessment points
(range, 39-195; higher scores indicate greater mindfulness).
Participants’ beliefs about the rationale and logic of the
treatment (credibility scale range, 1-9; higher scores indicate
more rationality/logic) and likelihood of the treatment’s suc-
cess (expectancy scale range, 1-9; higher scores indicate
greater expectations of success) in reducing PTSD symp-
toms were assessed using the Credibility/Expectancy
Questionnaire
29
at week 3. Participants reported treatment
satisfaction at week 9 using a scale ranging from 1 to 4 with
higher scales indicating greater satisfaction. Demographic
information, including self-reported race/ethnicity, was col-
lected at baseline to characterize the sample. Mental health
treatment history and psychotherapy health care visits (in-
dividual and group therapy delivered both in specialty PTSD
and mental health clinics) from October 1, 1999, to partici-
pants’ baseline dates were extracted from VA electronic
medical records. We determined the mean duration (in
months) of previous mental health care, total number of
psychotherapy mental health visits, and whether a partici-
pant had previously received 8 or more therapy sessions at
baseline.
Treatment Fidelity
All treatment sessions were videotaped. Two senior clini-
cians independent of treatment delivery rated 10% of ses-
sions from each condition using a rating tool adapted from
other trials of PTSD group treatment.
30
Data Analysis
Intention-to-treat analyses were conducted for all outcomes.
Baseline differences between groups were examined using
analysis of variance for continuously measured variables and
χ
2
statistics for noncontinuous variables. Mixed-effects mod-
els were used to analyze the efficacy of mindfulness-based
stress reduction compared with present-centered group
therapy in reducing PTSD symptoms over 9 weeks of treat-
ment and at 2-month follow-up.
31
Mixed-effects models are
flexible regression methods for incomplete repeated-
measures data and allow continuous and categorical covari-
ates, fixed and time-dependent covariates, and a specifica-
tion of unstructured as well as structured covariance matrix.
The analysis for each outcome consisted of a maximum like-
lihood growth curve model that included treatment, time,
and treatment × time interaction as fixed effects and the
intercept and slope as random effects with an unstructured
covariance matrix. Since treatment groups are expected to be
similar at baseline, the effect of treatment is captured
Research Original Investigation Mindfulness-Based Stress Reduction for PTSD Among Veterans
458 JAMA August 4, 2015 Volume 314, Number 5 (Reprinted) jama.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
through the treatment × time interaction (ie, differential
temporal patterns of PTSD symptoms for 2 treatment
groups). Between-group effect sizes were computed as
Cohen d, the standardized mean difference,
32
and defined as
small (d= 0.25), medium (d= 0.50), and large (d= 0.80). We
calculated the percentage of participants who showed clini-
cally significant improvement on primary and secondary out-
comes based on MCIDs established in the literature. Finally,
because of the sex imbalance between the groups, we also
conducted a series of exploratory growth curve models add-
ing sex as a control variable to determine the effect of this
imbalance on study findings.
Power analyses were based on expected effect sizes (0.5-
0.9) drawn from a prior pilot study
33
and estimates for
means, standard deviations, and covariances from an
unpublished open trial of mindfulness-based stress reduc-
tion in a group of 24 veterans with PTSD. Power analyses
were conducted for the primary outcome (PCL score) using
Nquery Advisor 4 (Statistics Solutions) under the following
assumptions: (1) repeated-measures analysis of variance
with main effects of treatment (mindfulness-based stress
reduction vs present-centered group therapy), time (0, 3, 6,
9, and 17 weeks), and treatment × time interaction; (2) com-
pound symmetric covariance matrix; and (3) α<.05 signifi-
cance level. A sample size of 60 to 65 patients after attrition
(we expected attrition of approximately 30%; hence, our ini-
tial recruiting goal was 90 per group) was estimated to pro-
vide 80% power to detect an effect size of d= 0.52. This
effect size corresponds to a difference in total scores
between groups of 6.4 for the PCL, 8.6 for the CAPS, 2.8 for
the PHQ-9, and 7.6 for the WHOQOL-BREF. All analyses were
conducted using SPSS software version 19.0 (IBM Corp). All
tests were 2-tailed and α<.05 was considered statistically sig-
nificant. No adjustment for multiple comparisons were
made, so secondary outcomes, including tests of MCIDs,
should be considered exploratory.
Results
Figure 1 depicts participant flow through the study. Table 1
provides information on demographics, mental health treat-
ment history, and trauma exposure for the sample. There
were no differences between groups in demographic charac-
teristics with the exception of ethnicity and sex. There were
more African American (10.3% [n = 6] vs 5.2% [n = 3]) and
American Indian (3.4% [n = 2] vs 0%) patients in the present-
centered therapy group, but there were more patients of
mixed ethnicity (10.3% [n = 6] vs 0%) and more women
(20.7% [n = 12] vs 10.3% [n = 6]) in the mindfulness-based
stress reduction group. Groups were similar in terms of
comorbid mood disorder, psychoactive medication use,
mental health treatment history, number of traumatic
events, combat exposure, and ratings of treatment credibil-
ity and expectancies. However, participants randomized to
mindfulness-based stress reduction therapy more frequently
reported a history of sexual trauma (37% [n = 21] vs 19%
[n = 11]) and had greater severity of PTSD symptoms at base-
lineasmeasuredbythePCL(meanscore,63.6vs58.8)and
CAPS (mean score, 69.9 vs 62.5) compared with participants
randomized to present-centered group therapy. There was
no difference in PTSD symptom severity as measured by the
PCL between those who met full PTSD and those who met
subthreshold PTSD (mean score, 61.2 vs 60.7). There were no
differences between groups in depression symptoms (PHQ-9
mean score, 15.5 vs 14.6), quality of life (WHOQOL-BREF
mean score, 75.6 vs 76.4), or mindfulness skills (FFMQ mean
score, 105.7 vs 108.1) reported at baseline.
From March 2012 to December 2013, 603 veterans were
screened and 167 completed clinical interviews to assess eli-
gibility; 118 were eligible and 116 were randomly assigned to
mindfulness-based stress reduction (n = 58) or present-
centered group therapy (n = 58). For each cohort, there was
an average of 6.4 (range, 4-11) veterans in each group.
Recruitment was terminated prior to reaching the target
recruitment goal of 90 per condition prior to attrition because
of lower-than-anticipated attrition rates and lack of sufficient
funds. Of the 116 participants randomized, 99 (85.3%) com-
pleted treatment, defined as receiving at least 7 of the pos-
sible 9 treatment sessions. The mean number of sessions
attended was 6.96 (SD, 2.56) in mindfulness-based stress
reduction and 8.08 (SD, 1.84) in present-centered group
therapy (P=.008). Treatment dropout was higher in
mindfulness-based stress reduction (22.4% [n = 13]) than in
present-centered group therapy (6.9% [n = 4]; χ
2
= 5.58;
P= .02). There were no differences in demographic or base-
line clinical characteristics between patients who completed
treatment and those who dropped out. There was 1 serious
adverse event in present-centered group therapy, in which a
patient made a suicide attempt. Adherence to prescribed ele-
ments of the treatment was 96.25% for mindfulness-based
stress reduction and 100% for present-centered group
therapy; use of proscribed elements was extremely low, with
no use of proscribed elements in mindfulness-based stress
reduction. For our primary outcome, the PCL, we obtained
93.6% of all possible assessments. We obtained 93.4% of all
possible interviewer-rated PTSD assessments and 93.5% of all
possible secondary self-report outcomes. We found no evi-
dence that missing data were due to any substantial demo-
graphic or clinical characteristics.
Primary Outcome
Figure 2 presents mean PCL scores from baseline to 2-month
follow-up. There was an initial increase in PTSD symptom se-
verity in both groups; however, this worsening of PTSD symp-
toms from baseline (mean score, 58.8) to week 3 (mean score,
61.7; t
55.8
= 8.4; P= .005) was significant for present-
centered group therapy participants only. There was a signifi-
cant group × time interaction in relation to PTSD symptom se-
verity (F
1,106.9
= 8.78; P= .004). Table 2 shows that mean PCL
scores improved from baseline to 2-month follow-up for both
groups (mindfulness-based stress reduction, from 63.6 to 54.4;
present-centered group therapy, from 58.8 to 56.0). How-
ever, growth curve mixed-effects models showed that im-
provement in mindfulness-based stress reduction was signifi-
cantly greater than improvement in present-centered group
Mindfulness-Based Stress Reduction for PTSD Among Veterans Original Investigation Research
jama.com (Reprinted) JAMA August 4,2015 Volume 314, Number 5 459
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
therapy (mean difference in improvement, 6.44;95% CI, 3.34-
9.53; t= 4.08; P< .001; d= 0.40).
Secondary Outcomes
All participants also showed significant improvements in in-
terview-rated PTSD severity on the CAPS from baseline to
2-month follow-up. However, a significant group × time in-
teraction showed that improvement was greater in mindful-
ness-based stress reduction than in present-centered group
therapy (F
1,106.8
= 4.75; P= .03; mean CAPS score improve-
ment: mindfulness-based stress reduction, from 69.9 to 49.8
vs present-centered group therapy, from 62.5 to 50.6;mean dif-
ference in improvement, 7.89; 95% CI, 2.58-10.6; t=2.91;
P=.004; d= 0.41). There was no difference between mindful-
ness-based stress reduction and present-centered group
therapy in rates of loss of diagnosis at posttreatment (42.3%
[n = 22] vs 43.9% [n = 25]; mean difference, 1.6%; 95% CI,
−20.6% to 17.4%; χ
2
=0.03;P= .87) or at 2-month follow-up
(53.3% [n = 24] vs 47.3% [n = 26]; mean difference, 6.0%; 95%
CI, −14.1% to 26.2%; χ
2
= 0.36; P= .55).
Mindfulness-based stress reduction participants re-
ported greater improvementin quality of life on the WHOQOL-
BREF from baseline to 2-month follow-up than did those in
present-centered group therapy (mean score improvement:
mindfulness-based stress reduction, from 75.6 to 80.2 vs
present-centered group therapy, from 76.4 to 75.8; mean dif-
ference in improvement, 5.22; 95% CI, 1.73-8.71; t=2.94;
P=.004; d= 0.41). While mindfulness-based stress reduction
participants reported greater improvementin depressive symp-
toms on the PHQ-9 from baseline to 2-month follow-up than
did those in present-centered group therapy, this differential
did not reach the level of significance (mean score improve-
ment: mindfulness-based stress reduction, from 15.5 to 13.3 vs
present-centered group therapy, from 14.6 to 13.8; mean dif-
ference in improvement, 1.34; 95% CI, −0.07 to 2.75; t=1.87;
P= .06; d=0.26).
Figure 1. Flow of Participants Through a Trial of Mindfulness-Based Stress Reduction vs Present-Centered
Group Therapy for Treatmentof Posttraumatic Stress Disorder
603 Individuals assessed for
eligibility via telephone
167 Individuals assessed for
eligibility via telephone
436 Excluded
238 Did not meet inclusion criteria
198 Declined to participate
51 Excluded
34 Did not meet inclusion criteria
2Eligible but declined to participate
10 Met exclusion criteria
5Other
116 Randomized
58 Included in primary analysis 58 Included in primary analysis
Follow-up
a
54 Assessed at week 3
50 Assessed at week 6
52 Assessed at week 9 (posttreatment)
47 Assessed at week 17 (2-mo follow-up)
Follow-up
a
56 Assessed at week 3
54 Assessed at week 6
57 Assessed at week 9 (posttreatment)
57 Assessed at week 17 (2-mo follow-up)
58 Randomized to receive mindfulness-based stress
reduction
45 Completed treatment as randomized (≥7 sessions)
10 Received some treatment
3Serious family illness/stressors
4Transportation/logistic difficulties
2Received no treatment
1Withdrawn from study by principal
investigator (met exclusion criteria)
1Different treatment clinically indicated
1Serious medical illness
1Intervention not perceived as helpful
1Increased symptoms; did not want to continue
1Unknown
58 Randomized to receive present-centered group therapy
54 Completed treatment as randomized (≥7 sessions)
4Received some treatment
1Serious family illness
1Transportation/scheduling difficulties
1Intervention not perceived as helpful
1Different treatment clinically indicated
a
Reasons for loss to follow-up are
unknown.
Research Original Investigation Mindfulness-Based Stress Reduction for PTSD Among Veterans
460 JAMA August 4, 2015 Volume 314, Number 5 (Reprinted) jama.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
Table 1. DemographicCharacteristics of the Intention-to-Treat Sample
a
Characteristics
Total
(n = 116)
Mindfulness-Based
Stress Reduction
(n = 58)
Present-Centered
Group Therapy
(n = 58)
Male 98 (84) 46 (79) 52 (90)
Female 18 (16) 12 (21) 6 (10)
Age, mean (SD), y 58.5 (9.8) 57.6 (10.4) 59.4 (9.2)
Race
White 97 (84) 47 (81) 50 (86)
Black 9 (8) 3 (5) 6 (10)
Other 4 (3) 2 (4) 2 (4)
Mixed 6 (5) 6 (10) 0
Service era
OEF/OIF 11 (10) 6 (10) 5 (9)
Gulf War 17 (15) 9 (16) 8 (14)
Vietnam War 86 (75) 41 (70) 45 (77)
Other 2 (1) 2 (4) 0
Lifetime trauma exposure, mean (SD),
No. of events
7.7 (3.1) 7.9 (3.3) 7.5 (3.0)
Event type
b
Combat exposure 86 (74) 39 (68) 47 (80)
Sexual trauma 32 (28) 21 (37) 11 (19)
Physical assault 76 (66) 39 (68) 37 (63)
Disaster exposure 50 (43) 25. (44) 25 (43)
Serious injury event 74 (64) 38 (67) 36 (61)
Life-threatening illness or injury 67 (58) 34 (60) 33 (56)
Other traumatic event
(eg, sudden, unexpected death
of someone close)
110 (95) 55 (97) 55 (93)
PTSD diagnosis
Full PTSD criteria 113 (97.4) 57 (98.3) 56 (96.6)
Subthreshold PTSD 3 (2.6) 1 (1.7) 2 (3.4)
Comorbid mood disorder 49 (42.2) 26 (44.8) 23 (39.7)
Taking psychotropic medication 100 (86) 51 (89.5) 49 (86.0)
Mental health treatment history
Duration of previous mental health care,
mean (SD), mo
66.5 (9.2) 69.0 (53.3) 63.9 (45.2)
Total No. of psychotherapy mental health
visits, mean (SD)
13.9 (28.7) 13.2 (28.3) 14.6 (29.2)
Receipt of ≥8 therapy sessions in PTSD
or mental health clinic
43 (37) 19 (33) 24 (41)
Baseline psychological assessment scores,
mean (SD)
c
Self-reported PTSD symptom severity
on the PCL
61.2 (12.3) 63.6 (11.1) 58.8 (13.1)
Interview-rated PTSD severity
on the CAPS
66.2 (16.5) 69.9 (15.5) 62.5 (16.9)
Self-reported depression symptom severity
on the PHQ-9
15.0 (5.3) 15.5 (5.0) 14.6 (5.6)
Quality of life on the WHOQOL-BREF 76.0 (14.6) 75.6 (11.9) 76.4 (16.9)
Mindfulness skills on the FFMQ 106.9 (16.2) 105.7 (15.3) 108.1 (17.1)
Credibility/Expectancy Questionnaire scores
at week 3, mean (SD)
d
Treatment credibility 6.62 (1.76) 6.49 (1.74) 6.74 (1.78)
Expectancy of therapeutic outcome 5.90 (1.83) 5.87 (1.72) 5.92 (1.95)
No. of treatment sessions completed,
mean (SD)
7.53 (2.3) 6.96 (2.6) 8.08 (1.8)
Treatment dropouts 17 (14.7) 13 (22.4) 4 (6.9)
Treatment satisfaction scores at week 9,
mean (SD)
d
2.82 (1.11) 2.88 (1.20) 2.77 (1.03)
Abbreviations: CAPS,
Clinician-Administered PTSD Scale;
FFMQ, Five Facet Mindfulness
Questionnaire; OEF/OIF, Operation
Enduring Freedom/Operation Iraqi
Freedom; PCL, PTSD Checklist;
PHQ-9, PatientHealth Questionnaire
9; PTSD, posttraumatic stress
disorder; WHOQOL-BREF, World
Health Organization Quality of
Life–Brief.
a
Data are expressed as No. (%)
unless otherwise indicated.
b
The 17 categories of the Life Events
Checklist
24
were aggregated as
shown to simplify presentation.
c
For descriptions of assessment
tool score ranges, see footnote to
Table 2.
d
For descriptions of score ranges, see
the Methods section of the text.
Mindfulness-Based Stress Reduction for PTSD Among Veterans Original Investigation Research
jama.com (Reprinted) JAMA August 4,2015 Volume 314, Number 5 461
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
A significant group × time interaction was observed in re-
lation to mindfulness skills from baseline to 2-month fol-
low-up (F
1,118.5
= 12.7; P= .001), with participants receiving
mindfulness-based stress reduction therapy reporting greater
improvement in mindfulness as measured by the FFMQ (mean
score improvement, mindfulness-based stress reduction, from
105.7 to 116.3 vs present-centered group therapy, from 108.1
to 108.6; mean difference in improvement, 9.73; 95% CI, 4.42-
15.04; t= 3.59; P<.001; d= 0.36). Improvementin FFMQ scores
from baseline to posttreatment for participants receiving mind-
fulness-based stress reduction therapy was associated with
greater reductions in PTSD symptom severity (PCL, r=−0.46;
CAPS, r= −0.33) and depressive symptoms (r=−0.44)aswell
as improved quality of life (r= 0.42) at 2-month follow-up.
Clinical Outcomes
Using a 10-point or greater reduction on the PCL as an indica-
tor of MCID,
23
we found that a greater percentage of partici-
pants receiving mindfulness-based stress reduction therapy
showed clinically significant improvement in PTSD symp-
tom severity at 2-month follow-up compared with partici-
pants receiving present-centeredgroup therapy (48.9% [n = 23]
vs 28.1% [n = 16]; mean difference, 20.9%; 95% CI, 2.2%-
39.5%; χ
2
= 4.79; P= .03). Using a 10-point or greater reduc-
tion on the CAPS, groups were similar in the percentage of par-
ticipants showing clinically significant improvement in
interview-rated PTSD symptom severity at 2-month follow-up
(mindfulness-based stress reduction, 66.7% [n = 30] vs present-
centered group therapy, 54.5% [n = 30]; mean difference, 12.1%;
95% CI, −7.5% to 31.7%; χ
2
= 1.52; P= .22). Treatments showed
similar percentages of participants reporting clinically signifi-
cant improvement in depressive symptoms on the PHQ-9
(mindfulness-based stress reduction, 27.7% [n = 13] vs present-
centered group therapy, 22.8% [n = 13]; mean difference, 4.9%;
95% CI, −12.2% to 21.9%; χ
2
= 0.32; P= .57).
Exploratory Analyses
Due to the imbalance in sex distribution at baseline, we con-
ducted a series of growth curve analyses controlling for sex.
For our primary outcome, we continued to find a significant
group × time interaction (F
1,106.7
= 8.80; P= .004). For second-
ary outcomes, the group × time interaction for interview-
rated PTSD severity was also significant (F
1,106.9
= 4.81; P= .03),
as were the interactions for the WHOQOL-BREF (F
1,109.4
= 4.99;
P= .03) and FFMQ (F
1,108.5
= 12.79; P= .001). The group × time
interaction for the PHQ-9 did not meet significance
(F
1,107.8
= 2.22; P= .14), as was the case before controlling
for sex.
Discussion
Findings from the present study provide support for the effi-
cacy of mindfulness-based stress reduction for the treatment
of PTSD among veterans. Participants randomized to receive
mindfulness-based stress reduction therapy showed greater
improvement in self-reported PTSD symptom severity during
treatment than those randomized to receive present-
centered group therapy. However, the magnitude of the aver-
age improvement suggests a modest effect. Results of this
study also support the modestly increased efficacy of
mindfulness-based stress reduction therapy through the
2-month follow-up, with participants randomized to
mindfulness-based stress reduction therapy showing greater
improvement in both self-reported and interview-rated PTSD
severity than those randomized to present-centered group
therapy. Participants receiving mindfulness-based stress
reduction therapy appeared to demonstrate improvements in
depressive symptoms and quality of life after treatment, but
these improvements were not observed among those who
received present-centered group therapy.
These findings are consistent with previous studies
demonstrating robust changes in anxiety and depressive
symptoms between pretreatment and posttreatment.
34
However, pilot studies evaluating mindfulness-based
stress reduction as a treatment for PTSD have shown
mixed results. While promising, previous studies had
methodological shortcomings, including small sample
sizes,
33,35,36
pre-post designs,
33,37
and lack of blinding of out-
come assessments
33,35-37
and evaluation of treatment
fidelity,
33,35-37
which preclude clear conclusions regarding
efficacy.
13
Few previous studies have evaluated the efficacy
of mindfulness-based stress reduction relative to active
treatment controls.
36
Our findings add to the literature by
demonstrating the comparative efficacy of mindfulness-
based stress reduction for improving PTSD as well as possi-
bly improving depressive symptoms and quality of life. Sus-
tained improvements in PTSD symptoms observed at
2-month follow-up in the current study are consistent with
pilot findings reported by Kearney et al
37
but challenge those
of Kearney et al
35
showing no effect on PTSD and those of
Niles et al
36
showing clinically significant albeit temporary
improvements in PTSD symptoms following mindfulness-
based stress reduction therapy.
Figure 2. Posttraumatic Stress Disorder Symptom Severityon the PTSD
Checklist (PCL) as a Function of Treatment Group
68
58
60
62
66
64
56
54
52
Treatment
completed
50
Mean PCL Total Score
Week
No. of patients
Mindfulness-based
stress reduction
Present-centered
group therapy
Baseline
58
58
3
54
56
6
50
54
9
52
57
12 15 17
47
57
Mindfulness-based stress
reduction
Present-centered group
therapy
Data are intention-to-treat means; error bars indicate 95% CIs.
Research Original Investigation Mindfulness-Based Stress Reduction for PTSD Among Veterans
462 JAMA August 4, 2015 Volume 314, Number 5 (Reprinted) jama.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
Table 2. Primary and Secondary Outcomes at Baseline, During Treatment, After Treatment, and at 2-Month Follow-up
a
Outcomes
Total
(n = 116)
Mindfulness-Based
Stress Reduction
(n = 58)
Present-Centered
Group Therapy
(n = 58)
Between-Treatment
Differences in
Improvement
From Baseline
P
Value
Primary outcome: self-reported PTSD
symptom severity scores on the PCL
b
Baseline 61.2 (59.0-63.4) 63.6 (60.6-66.7) 58.8 (55.7-61.8)
Week 3 62.8 (60.6-65.0) 63.9 (60.8-67.0) 61.7 (58.6-64.8) 2.66 (−0.36 to 5.68) .09
Week 6 61.0 (58.8-63.2) 61.3 (58.1-64.4) 60.7 (57.6-63.8) 4.45 (1.37 to 7.52) .005
Posttreatment, week 9 55.8 (53.6-58.0) 55.7 (52.6-58.9) 55.8 (52.7-58.9) 4.95 (1.92 to 7.99) .002
2-mo follow-up, week 17 55.2 (53.0-57.4) 54.4 (51.2-57.6) 56.0 (52.9-59.0) 6.44 (3.34 to 9.53) <.001
Secondary outcomes
Interview-rated PTSD severity
scores on the CAPS
c
Baseline 66.2 (62.7-69.7) 69.9 (65.0-74.8) 62.5 (57.6-67.4)
Posttreatment, week 9 54.0 (50.3-57.7) 56.3 (51.0-61.5) 51.7 (46.5-56.8) 2.35 (−2.75 to 7.45) .37
2-mo follow-up, week 17 50.2 (46.4-54.0) 49.8 (44.3-55.3) 50.6 (45.4-55.8) 7.89 (2.58 to 10.6) .004
Loss of diagnosis of PTSD,
% (95% CI)
Posttreatment, week 9 43.1 (.34-.53) 42.3 (.28-56) 43.9 (.31-.57) 1.6 (−20.6 to 17.4) .87
Two-month follow-up, week 17 50.0 (.40-.60) 53.3 (.38-.68) 47.3 (.34-.61) 6.0 (−14.1 to 26.2) .55
Self-reported depression symptom
severity scores on the PHQ-9
d
Baseline 15.0 (13.9-16.1) 15.5 (13.9-17.0) 14.6 (13.1-16.2)
Posttreatment, week 9 13.7 (12.6-14.8) 13.6 (12.0-15.1) 13.9 (12.3-15.4) 1.17 (−0.22 to 2.56) .10
2-mo follow-up, week 17 13.6 (12.4-14.7) 13.3 (11.7-15.0) 13.8 (12.2-15.4) 1.34 (−0.07 to 2.75) .06
Quality-of-life scores
on the WHOQOL-BREF
e
Baseline 76.0 (73.1-78.9) 75.6 (71.6-79.7) 76.4 (72.3-80.4)
Posttreatment, week 9 79.6 (76.7-82.5) 80.7 (76.5-84.8) 78.5 (74.4-82.6) 3.10 (−0.29 to 6.49) .08
2-mo follow-up, week 17 78.0 (75.0-80.9) 80.2 (75.9-84.4) 75.8 (71.7-79.9) 5.22 (1.73 to 8.71) .004
Mindfulness skills scores
on the FFMQ
f
Baseline 106.9 (103.7-110.2) 105.7 (101.2-110.3) 108.1 (103.5-112.7)
Week 3 106.4 (103.1-109.7) 106.7 (102.0-111.3) 106.1 (101.4-110.7) 2.63 (−2.58 to 7.84) .32
Week 6 109.3 (106.0-112.7) 111.1 (106.3-115.9) 107.5 (102.9-112.2) 5.34 (0.02 to 10.65) .05
Posttreatment, week 9 112.7 (109.4-116.0) 116.3 (111.6-121.0) 109.2 (104.5-113.8) 9.14 (3.91 to 14.37) <.001
2-mo follow-up, week 17 112.4 (109.1-115.8) 116.3 (111.4-121.1) 108.6 (103.9-113.2) 9.73 (4.42-15.04) <.001
Clinically significant improvement
in outcomes, % (95% CI)
[No. of participants]
PCL scores
b
Posttreatment, week 9 29.4 (20.4-38.3) [n=32] 36.5 (24.0-49.0) [n=19] 22.8 (10.9-34.7) [n=13] 13.7 (−3.5 to 31.0) .12
2-mo follow-up, week 17 37.5 (28.2-46.4) [n=39] 48.9 (35.1-62.8) [n=23] 28.1 (15.5-40.6) [n=16] 20.9 (2.2 to 39.5) .03
CAPS scores
c
Posttreatment, week 9 56.3 (46.9-65.7) [n=61] 63.5 (49.8-77.1) [n=33] 49.1 (36.1-62.1) [n=28] 14.3−4.5 to 33.2 .13
2-mo follow-up, week 17 60.6 (50.8-70.4) [n=60] 66.7 (52.1-81.2) [n=30] 54.5 (41.4-67.7) [n=30] 12.1 (−7.5 to 31.7) .22
PHQ-9 scores
d
Posttreatment, week 9 24.5 (16.3-32.8) [n=26] 29.4 (17.5-41.4) [n=15] 19.6 (8.2-31.0) [n=11] 9.8 (−6.7 to 26.3) .24
2-mo follow-up, week 17 25.2 (16.7-33.8) [n=26] 27.7 (15.0-40.3) [n=13] 22.8 (11.3-34.3) [n=13] 4.9 (−12.2 to 21.9) .57
Abbreviation: PTSD, posttraumatic stress disorder.
a
Data are expressed as mean [95% CI] unless otherwise indicated.
b
PTSD Checklist [PCL] range: 17-84, higher scores indicate greater
symptomatology with clinically significant improvement in PTSD symptom
severity defined as reduction of 10 points or more on the PCL.
c
Clinician-Administered PTSD Scale [CAPS] range: 0-136;higher scores indicate
more severe PTSD with clinically significant improvement in interviewer-rated
PTSD symptom severity defined as a reduction of 10 points or more
on the CAPS.
d
Patient Health Questionnaire 9 [PHQ-9] range: 0-27; higher scores indicate
greater depressive symptoms with clinically significant improvement in
depressive symptoms defined as a reduction of 5 points or more on the
PHQ-9.
e
World Health Organization Quality of Life–Brief [WHOQOL-BREF] range:
0-130; higher scores indicate greater quality of life.
f
Five Facet Mindfulness Questionnaire [FFMQ] range: 39-195; higher scores
indicate greater mindfulness.
Mindfulness-Based Stress Reduction for PTSD Among Veterans Original Investigation Research
jama.com (Reprinted) JAMA August 4,2015 Volume 314, Number 5 463
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
The findings of the present study are consistent with pre-
vious studies showing that mindfulness-based stress reduc-
tion is well tolerated by trauma survivors and veterans with
PTSD.
33,35,36
Although treatment dropout was higher among
those randomized to mindfulness-based stress reduction
therapy than to present-centered group therapy (22.4% vs
6.9%), dropout rates were lower than those reported for vet-
erans receiving prolonged exposure (28.1%-44%)
5,8,9,11
and cog-
nitive processing therapy (26.8%-35%)
6,7,19
in clinical trials and
real-world treatment settings.
Half to two-thirds of patients who received mindfulness-
based stress reduction therapy showed clinically meaningful
treatment benefits at 2-month follow-up (48.9% based on the
PCL; 66.7% based on the CAPS). These clinical response rates
are similar to those reported for first-line PTSD treatments with
veterans (49%-68.8%).
5,6,11,19
Yet half of participants in both
groups continued to meet criteria for PTSD diagnosis at
2-month follow-up.
Findings from the present study suggest that veteranswho
received mindfulness-based stress reduction therapy re-
ported significant improvement in mindfulness skills after
treatment, while there appeared to be little change in mind-
fulness skills reported by veterans who received present-
centered group therapy. Moreover, findings suggest that greater
reductions in PTSD symptom severity were associated with
changes in mindfulness over the course of treatment.Improve-
ments in quality of life made during treatment appeared tobe
maintained through the 2-month follow-upfor partic ipantsre-
ceiving mindfulness-based stress reduction therapy, but re-
ports of quality of life appeared to return to baseline levels for
present-centered group therapy participants during this same
follow-up period. Taken together, these findings suggest that
mindfulness-based stress reduction may provide veterans with
internal tools for promoting self-management of PTSD symp-
toms and quality of life.
The quality of scientific evidence supporting the efficacy
of mindfulness-based interventions has recently been
criticized.
13
This study improves on shortcomings of previous
trials by comparing mindfulness-based stress reduction with
an active, credible control condition, taking steps to ensure
treatment fidelity, and using both patient-reported and
blinded clinician ratings of PTSD outcomes.
13
Although
groups were structurally equivalent in number of weekly ses-
sions, therapist training and qualifications, and group for-
mat, present-centered group therapy may not have fully
accounted for all nonspecific factors present in mindfulness-
based stress reduction (eg, therapist expectations) and was
unequal in duration of sessions. Because our intent was to
study mindfulness-based stress reduction in the format it is
typically taught (2.5-hour group sessions) compared with
present-centered group therapy as generally provided within
the VA system (1.5-hour group sessions), participants
received less contact with clinicians in the control condition
(13.5 hours) than in mindfulness-based stress reduction (26.5
hours). Another important limitation was the short follow-up
period. Given the chronicity of the study group in terms of
treatment history and modest average treatment effects
observed in this study, it is possible that some participants
may have relapsed after the 2-month follow-up. Future trials
with longer-term follow-up (≥6 months) are needed to evalu-
ate the durability of treatment benefits over time. Despite
randomization and inclusion criteria requiring diagnosis of
PTSD or subthreshold PTSD, the 2 groups differed in baseline
PTSD symptom severity, with present-centered group
therapy participants reporting lower symptoms. This limita-
tion may have influenced results. Current findings are also
limited by the sample, predominantly white men from 1 geo-
graphical region who served during the Vietnam era, and
results may not generalize to nonveterans or veterans from
other eras or areas. Replication with more diverse samples at
additional centers is needed.
Conclusions
Among veterans with PTSD, mindfulness-based stress reduc-
tion therapy, compared with present-centered group therapy,
resulted in a greater decrease in PTSD symptom severity. How-
ever, the magnitude of the average improvement suggests a
modest effect.
ARTICLE INFORMATION
Author Contributions: Dr Polusny had full access
to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Polusny,Erbes,
Lamberty, Rodman,Lim.
Acquisition, analysis, or interpretation of data:
Polusny,Erbes, Thuras, Moran, Lamberty, Collins,
Lim.
Drafting of the manuscript: Polusny, Thuras.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Thuras.
Obtained funding: Polusny,Erbes, Lim.
Administrative, technical, or material support:
Moran, Collins, Rodman, Lim.
Study supervision: Polusny, Erbes, Lamberty, Lim.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Funding/Support: This material is the result of
work supported with resources and the use of
facilities at the Minneapolis VA Health Care System,
Minneapolis, Minnesota. This research was
supported by VA grant 5I01CX000683-01
to Dr Lim.
Role of the Funder/Sponsor:The funder had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; or decision to submit
the manuscript for publication.
Disclaimer: The views expressed in this article are
those of the authors and do not reflect the official
policy or position of the VA.
Additional Contributions: Minneapolis VA Health
Care System clinicians TorriciaYamada, PhD,
Carolyn Anderson, PhD, Maureen Kennedy, PsyD,
Kelly Petska, PhD, JacquelineWright, LIC SW, Nancy
Koets, PsyD, Margaret Gavian, PhD,and Ivy Miller,
PhD, contributed to intervention delivery as part of
their provision of clinical care. Mariann Johnson,
BA, University of Minnesota Center for Spirituality
and Healing, contributed to intervention delivery
and was provided compensation for her role in the
study.Terry Pearson, RPh, MBA, University of
Minnesota Center for Spirituality and Healing,
provided consultation on mindfulness-based stress
reduction and evaluation of treatment fidelity and
was provided compensation for her role in the
study.Melissa Wattenberg, PhD, VA Boston
Healthcare System and Boston University School of
Medicine, provided training and consultation on
present-centered group therapy, for which she
received no compensation. Leah Gause, MA, and
Research Original Investigation Mindfulness-Based Stress Reduction for PTSD Among Veterans
464 JAMA August 4, 2015 Volume 314, Number 5 (Reprinted) jama.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015

Copyright 2015 American Medical Association. All rights reserved.
Cassandra Sartor, MA, Minneapolis VAHealth Care
System, served as independent assessors and were
provided compensation for their roles in the study.
Doris Clancy, MA, and Cory Voecks,MA , provided
administrative support and were provided
compensation for their roles in the study.Elizabeth
Gibson, BA, Minneapolis VA Health Care System,
provided editing assistance and received no
compensation.
REFERENCES
1. Fulton JJ, Calhoun PS, Wagner HR, et al. The
prevalence of posttraumatic stress disorder in
Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF)veterans: a meta-analysis.
J Anxiety Disord. 2015;31:98-107.
2. Kessler RC. Posttraumatic stress disorder: the
burden to the individual and to society. J Clin
Psychiatry. 2000;61(suppl 5):4-12.
3. Karlin BE, Ruzek JI, Chard KM, et al.
Dissemination of evidence-based psychological
treatments for posttraumatic stress disorder in the
Veterans Health Administration. J Trauma Stress.
2010;23(6):663-673.
4. Institute of Medicine. Treatment of
Posttraumatic Stress Disorder: An Assessmentof the
Evidence. Washington, DC: National Academies Press;
2007.
5. Schnurr PP, FriedmanMJ, Engel CC, et al.
Cognitive behavioral therapy for posttraumatic
stress disorder in women: a randomized controlled
trial. JAMA. 2007;297(8):820-830.
6. Forbes D, Lloyd D, Nixon RD,et al. A multisite
randomized controlled effectiveness trial of
cognitive processing therapy for military-related
posttraumatic stress disorder.J Anxiety Disord.
2012;26(3):442-452.
7. Surís A, Link-Malcolm J, Chard K, Ahn C, North C.
A randomized clinical trial of cognitive processing
therapy for veterans with PTSD related to military
sexual trauma. J TraumaStress. 2013;26(1):28-37.
8. Tuerk PW, Yoder M, Grubaugh A, Myrick H,
Hamner M, Acierno R. Prolonged exposure therapy
for combat-related posttraumatic stress disorder:
an examination of treatment effectiveness for
veterans of the wars in Afghanistan and Iraq.
J Anxiety Disord. 2011;25(3):397-403.
9. Jeffreys MD, Reinfeld C, Nair PV, Garcia HA,
Mata-Galan E, Rentz TO. Evaluating treatment of
posttraumatic stress disorder with cognitive
processing therapy and prolonged exposure
therapy in a VHA specialty clinic. J Anxiety Disord.
2014;28(1):108-114.
10. Kehle-Forbes SM, Meis LA, Spoont MR, Polusny
MA. Treatment initiation and dropout from
prolonged exposure and cognitive processing
therapy in a VA outpatient clinic [published online
June 29, 2015]. Psychol Trauma. doi:10.1037
/tra0000065.
11. Eftekhari A, Ruzek JI, Crowley JJ, Rosen CS,
Greenbaum MA, Karlin BE. Effectiveness of national
implementation of prolonged exposure therapy in
Veterans Affairs care. JAMA Psychiatry. 2013;70(9):
949-955.
12. Kabat-Zinn J. Full Catastrophe Living: Using the
Wisdom of Your Body and Mind toFace Stress, Pain,
and Illness. New York, NY: Random House Publishing
Group; 1990.
13. Goyal M, Singh S, Sibinga EM, et al. Meditation
programs for psychological stress and well-being:
a systematic review and meta-analysis. JAMA Intern
Med. 2014;174(3):357-368.
14. Lang AJ, Strauss JL, Bomyea J, et al. The
theoretical and empirical basis for meditation as an
intervention for PTSD. Behav Modif. 2012;36(6):
759-786.
15. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders. 4th ed,
text revision. Washington, DC: American Psychiatric
Association; 2000.
16. Blake DD, Weathers FW, Nagy LM, et al. The
development of a Clinician-Administered PTSD
Scale. J Trauma Stress.1995;8(1):75-90.
17. First MB, Spitzer RL, Gibbon M, Williams JBW.
Structured Clinical Interview for DSM-IV-TR Axis I
Disorders, Research Version, Non-patient Edition
(SCID-I/NP). New York: Biometrics Research, New
York State Psychiatric Institute;2002.
18. Frost ND, Laska KM, Wampold BE. The
evidence for present-centered therapy as a
treatment for posttraumatic stress disorder.
J Trauma Stress.2014;27(1):1-8.
19. Resick PA, Wachen JS, Mintz J, et al.
A randomized clinical trial of group cognitive
processing therapy compared with group
present-centered therapy for PTSD among active
duty military personnel [published online May 4,
2015]. J Consult Clin Psychol. doi:10.1037
/ccp0000016.
20. Foy DW, Unger WS, WattenbergMS. Module 4:
an overview of evidence-based group approaches
to trauma with adults. In: Group Interventions for
Treatment ofP sychologicalTrauma. New York, NY:
American Group Psychotherapy Association;
2004:116-166.
21. Weathers FW, Litz BT, Herman DS, Huska JA,
Keane TM, eds. The PTSD Checklist (PCL):
reliability,validity, and diagnostic utility.Paper
presented at: Annual Meeting of the International
Society for Traumatic Stress Studies; October 1993;
San Antonio, TX.
22. Weathers FW, Ruscio AM, Keane TM.
Psychometric properties of 9 scoring rules for the
Clinician-Administered Posttraumatic Stress
Disorder Scale. Psychol Assess. 1999;11:124-133.
23. Monson CM, Gradus JL, Young-XuY, Schnurr
PP, Price JL, Schumm JA. Change in posttraumatic
stress disorder symptoms: do clinicians and
patients agree? Psychol Assess. 2008;20(2):131-138.
24. Gray MJ, Litz BT,Hsu JL , LombardoT W.
Psychometric properties of the life events checklist.
Assessment. 2004;11(4):330-341.
25. Kroenke K, Spitzer RL, Williams JB. The PHQ-9:
validity of a brief depression severity measure.
J Gen Intern Med. 2001;16(9):606-613.
26. Löwe B, Unützer J, Callahan CM, Perkins AJ,
Kroenke K. Monitoring depression treatment
outcomes with the patient health questionnaire-9.
Med Care. 2004;42(12):1194-1201.
27. Skevington SM, Lotfy M, O’Connell KA;
WHOQOL Group. The World Health Organization’s
WHOQOL-BREF quality of life assessment:
psychometric properties and results of the
international field trial. Qual Life Res. 2004;13(2):
299-310.
28. Baer RA, Smith GT, Hopkins J, KrietemeyerJ,
Toney L. Using self-report assessment methods to
explore facets of mindfulness. Assessment. 2006;13
(1):27-45.
29. Devilly GJ, Borkovec TD. Psychometric
properties of the credibility/expectancy
questionnaire. J Behav Ther Exp Psychiatry. 2000;
31(2):73-86.
30. Schnurr PP, FriedmanMJ, Foy DW, et al.
Randomized trial of trauma-focused group therapy
for posttraumatic stress disorder: results from a
department of veterans affairs cooperative study.
Arch Gen Psychiatry. 2003;60(5):481-489.
31. Gueorguieva R, Krystal JH. Move over ANOVA:
progress in analyzing repeated-measures data and
its reflection in papers published in the Archives of
General Psychiatry.Arch Gen Psychiatry. 2004;61
(3):310-317.
32. Cohen J. Statistical Power Analysis for the
Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence
Erlbaum Associates; 1988.
33. Kimbrough E, Magyari T, Langenberg P,
Chesney M, Berman B. Mindfulness intervention
for child abuse survivors. J Clin Psychol. 2010;66(1):
17-33.
34. Strauss C, Cavanagh K, Oliver A, Pettman D.
Mindfulness-based interventions for people
diagnosed with a current episode of an anxiety or
depressive disorder: a meta-analysis of randomised
controlled trials. PLoS One. 2014;9(4):e96110.
35. Kearney DJ, McDermott K, Malte C, Martinez M,
Simpson TL. Effects of participation in a
mindfulness program for veterans with
posttraumatic stress disorder: a randomized
controlled pilot study.J Clin P sychol.2013;
69(1):14-27.
36. Niles BL, Klunk-Gillis J, Ryngala DJ, Silberbogen
AK, Paysnick A, Wolf EJ. Comparing mindfulness
and psychoeducation treatments for
combat-related PTSD using a telehealth approach.
Psychol Trauma.2012;4:538-547.
37. Kearney DJ, McDermott K, Malte C, Martinez M,
Simpson TL. Association of participation in a
mindfulness program with measures of PTSD,
depression and quality of life in a veteran sample.
J Clin Psychol. 2012;68(1):101-116.
Mindfulness-Based Stress Reduction for PTSD Among Veterans Original Investigation Research
jama.com (Reprinted) JAMA August 4,2015 Volume 314, Number 5 465
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 08/06/2015