Indian Journal of Gastroenterology

https://doi.org/10.1007/s12664-019-00940-z

ORIGINAL ARTICLE

The effectiveness of mindfulness meditation in relief of symptoms

of depression and quality of life in patients with gastroesophageal
reflux disease
Suhas Chandran 1 & Rajesh Raman 1 & M. Kishor 1 & H. P. Nandeesh 2

Received: 6 August 2018 / Accepted: 10 January 2019

# Indian Society of Gastroenterology 2019

Abstract
Background The role of psychological comorbidities in patients with gastroesophageal reflux disease (GERD), a common
condition, still remains incompletely understood. Depression may intensify the symptoms and lower quality of life in these
patients. In this study, we looked at the effectiveness of mindfulness-based stress reduction (MBSR) in relieving the symptoms of
depression and the health-related quality of life of these patients.
Methods A longitudinal, interventional open-label study was carried out on 60 patients with GERD and 60 controls. Zung Self-
Rating Depression Scale (ZSDS) was used for assessing depression before and after the intervention. The GERD-Health-Related
Quality of Life (GERD-HRQL) questionnaire was used to assess the health-related quality of life and the Freiburg Mindfulness
Inventory (FMI) to quantify the amount of mindfulness over the study period. The correlation between the above variables was
analyzed.
Result Compared with the group not receiving MBSR, the group receiving MBSR showed a greater decrease in the levels of
depression indicated by changes in the ZSDS (p < 0.001). According to the GERD-HRQL questionnaire, mental health and social
functioning significantly correlated with symptoms of depression and reduction in the levels of distress and in the improvement in
health-related quality of life were greater in the group receiving MBSR (p < 0.001).
Conclusion Depressive symptoms adversely influence GERD, reducing the overall quality of life. MBSR can be an effective
modality in the alleviation of these symptoms and in reduction in the levels of distress in GERD patients.

Keywords Depression . Gastroesophageal reflux disease . Mindfulness-based stress reduction . Quality of life

* Suhas Chandran
suhaschandran90@gmail.com

1
Department of Psychiatry, JSS Medical College and Hospital, JSS
Academy of Higher Education and Research, Mysore-Bangalore
Road, Bannimantap, Mysuru 570 015, India
2
Department of Gastroenterology, JSS Medical College and Hospital,
JSS Academy of Higher Education and Research, Mysore-Bangalore
Road, Bannimantap, Mysuru 570 015, India
 Indian J Gastroenterol

Bullet points of the study highlights

What is already known?

Psychological factors influence the patient’s perception of the physiological
symptoms of gastroesophageal reflux disease (GERD).
Studies have shown that the psychological scores for depression were higher in
patients with GERD than in healthy controls and are found to be positively
correlated with symptoms of heartburn.
Psychological intervention can conceivably improve not only the general well-
being and quality of life of patients with gastrointestinal symptoms but can also
influence the outcome of medical and surgical treatments.

What are new findings in this study?

To the best of our knowledge, no previous study has assessed the role of
mindfulness-based stress reduction (MBSR) in improving symptoms of depression
in GERD and its impact on quality of life.
Depressive symptoms adversely influence GERD, reducing the overall quality of
life. MBSR can be an effective modality in alleviation of these symptoms and
reducing the levels of distress among these patients
.

What are the future clinical and research implications of the study findings?
Psychological interventions such as MBSR may be an useful adjunct for treatment of
patients with GERD.
GERD can be classified as erosive reflux disease or non-erosive reflux disease
and the prevalence of depression could differ between these groups and
similarly the response to mindfulness-based therapy, warranting an investigation.

Introduction 2011, a study reported a 7.6% prevalence of GERD in India,

The first-ever global general agreement on the definition of
gastroesophageal reflux disease (GERD) was published by the
BMontreal group^ in 2006. They described GERD as BA con-
dition which develops when the reflux of stomach contents
causes troublesome symptoms and/or complications^ [1].
GERD is a common health problem comprising of typical
symptoms like acid regurgitation and heartburn at least twice
weekly. It negatively influences the quality of life and, if left
unaddressed, can potentially lead on to outcomes such as
Barrett’s esophagus, esophageal strictures, and adenocarcino-
ma [2]. The prevalence of GERD is reported to be 2.5% to
7.8% in East Asia, 8.8% to 25.9% in Europe, and 18.1% to
27.8% in North America [3]. The prevalence of GERD might
have increased conspicuously in the last few decades [4]. In
whereas, in January 2017, another study reported a higher
prevalence of 39.2% [5, 6].
In clinical practice, a significant mismatch is noted between
the endoscopic severity of GERD, the patient’s experience of
the symptom complex, and the impairment of quality of life.
This discordance cannot, however, be explained by morpholog-
ic findings alone, and has to be ascribed to the psychological
factors in accordance with the biopsychosocial model of the
disease. The Montreal definition as previously stated assumes
that symptom evolution in GERD depends solely on the pres-
ence of an intra-esophageal stimulus. This definition, however,
ignores the impact of central factors, especially that of psycho-
logical comorbidities on the patient’s impression of GERD-
related symptoms in the presence or absence of abnormal
intra-esophageal stimuli [7]. The biopsychosocial model of
Indian J Gastroenterol
diseases is an important etiological paradigm in the course of
developing a holistic view about GERD and GERD-like disor-
ders [8]. Factors like stress, resilience, coping skills, personality
traits, and/or psychiatric comorbidities interact through psycho-
physiological and behavioral processes to determine the clinical
presentation of GERD. Identifying these probable levels of in-
teraction has compelling implications for elucidating the evolu-
tion and the sensitivity of GERD symptoms as well as in the
selection of an optimal therapeutic intervention. According to
clinical data, psychological factors, namely anxiety and depres-
sion also develop in patients with GERD and represent com-
mon comorbidities [9]. Studies have shown that the psycholog-
ical scores for depression were higher in patients with GERD
than those in healthy controls and positively correlate with
heartburn [10, 11]. Jansson and colleagues in a population-
based study in Stockholm, Sweden, evaluated 3153 GERD
patients for psychological comorbidity as compared with
40,210 normal subjects. Subjects reporting anxiety without de-
pression had a 3.2-fold increased risk of reflux, subjects with
depression without anxiety had a 1.7-fold increased risk of re-
flux, and subjects with both anxiety and depression had a 2.8-
fold increased risk of reflux when compared with subjects with-
out anxiety/depression [12]. Yang et al. in 2015 studied 279
consecutive patients in China with typical symptoms of
GERD. The scores for depression and quality of life (QOL) of
the two groups were analyzed. They found that depression may
play an important role in the occurrence of GERD and that the
QoL of patients with GERD is reduced in such patients [9].
In clinical settings, the treatment of GERD is primarily fo-
cused on symptomatic relief. Proton pump inhibitors (PPIs)
provide the most efficacious relief of the symptoms of GERD
and result in esophageal healing [13]. Failure of the PPI treat-
ment to resolve GERD-related symptoms has become one of
the most common presentations of GERD in patients seen by
the clinical gastroenterologists [14]. In a systematic review, El-
Serag et al. reported that persistent and troublesome GERD
symptoms remained in 17% to 32% of primary care patients
receiving PPI therapy and 45% of participants reported persis-
tent GERD symptoms in primary care and community-based
studies [15]. Several potential causes for PPI failure have been
recognized, including poor compliance, weak acidic reflux, bile
reflux, delayed gastric emptying, and visceral hypersensitivity
[16]. The role of psychological comorbidity and emotional
stress in PPI failure is also gaining attention now.
Generally, the aim of any GERD therapy, besides achieve-
ment of a disease-free state and improvement in quality of life, is
the healing of esophagitis and prevention of development of
complications of the disease. Psychological intervention can
conceivably improve not only the general well-being and
QOL of patients with gastrointestinal (GI) symptoms but can
also influence the outcome of medical and surgical treatments.
Psychological modalities such as hypnotherapy, relaxation tech-
niques, biofeedback, and cognitive behavior therapy are likely to
have a therapeutic role in these patients and a few of these
modalities have been studied earlier [17, 18]. Nevertheless, the
efficacy of these modalities has been mild to moderate at most
[19]. However, the potential of mindfulness-based therapies in
GERD still remains an unexplored management option. A meta-
analysis by Hofmann et al. examined 39 studies including 1140
participants receiving mindfulness-based therapy for a range of
conditions, including cancer, generalized anxiety disorder, de-
pression, and other psychiatric or medical conditions. They
found mindfulness-based therapy to be moderately effective in
improving anxiety and mood symptoms [20]. Mindfulness is the
intentional focusing of one’s attention on awareness of the pres-
ent moment. This awareness circumscribes the physical sensa-
tions of external sensory inputs and interoception (an awareness
of internal bodily sensations). Furthermore, attention is especial-
ly focused on cognition and emotions [21].
While the relationship between GERD and psychological
disorders has been recognized in the literature, presently there
are very few studies that throw light on the optimal manage-
ment of GERD patients with psychological comorbidities.
This study evaluated the effectiveness of a mindfulness
meditation-based therapy, namely mindfulness-based stress
reduction in alleviating symptoms of depression in GERD
patients and its role in reducing the levels of distress.
Methods
This was an open-label interventional study with an objective
to assess the depression in patients with GERD, the levels of
distress due to the GERD symptoms, and the effectiveness of
mindfulness meditation in improving the levels of depression
and distress over a 3-month follow up period.
Participants and procedure
The study was carried out at a tertiary care hospital in Mysore,
Karnataka, India. Approval was obtained from the institutional
ethical committee prior to its initiation. The investigation includ-
ed 120 patients diagnosed with GERD by the gastroenterologist
on the basis of symptoms and endoscopic findings (Los Angeles
classification) and those who, during the clinical interview, re-
ported symptoms of depression. They were then referred to the
psychiatrist for inclusion in the study. The subjects were ex-
plained about the nature of the study and were included only
after obtaining valid written consent. Patients were excluded for
the following reasons: use of non-steroidal anti-inflammatory
drugs (NSAIDs), previous treatment with a proton pump inhib-
itor (those treated with H2-blockers were allowed to participate if
the treatment has been discontinued 14 days prior to inclusion),
peptic stricture or duodenal and/or gastric ulcer visible on upper
endoscopy, a history of upper GI surgery, comorbidities
(such as scleroderma, diabetes mellitus, autonomic or

peripheral neuropathy, myopathy, functional bowel disor-
der, or any underlying disease or medication that might
affect the lower esophageal sphincter pressure or increase
the acid clearance time), inability or unwillingness to fully
complete all stages of the study, and inability or unwilling-
ness to provide informed consent. The Mini International
Neuropsychiatric Interview questionnaire (MINI-Plus) was
used to rule out an Axis I psychiatric disorder. Two hun-
dred eleven patients were screened for eligibility and con-
sidered for inclusion in the study and control groups. Both
the groups were then evaluated for levels of depression and
distress using the Zung Self-Rating Depression Scale and
the GERD-Health-Related Quality of Life (GERD-HRQL)
Scale, respectively. The Freiburg Mindfulness Inventory
(FMI) was then applied to quantify the inherent amount
of mindfulness present.
The patients in both the study and control groups were
advised lifestyle modifications including dietary changes and
were treated with a PPI to reduce the reflux symptoms. The
study group however, in addition to this, received an eight-
week mindfulness-based stress reduction (MBSR) course,
which was not administered to the control group. The
above-mentioned questionnaires were once again used
3 months after the intervention to evaluate for the change in
levels of depression, quality of life, and mindfulness in both
the study and control groups.
MBSR is based on the mindfulness training modules
dev eloped by Kab at-Zinn and Hanh [ 22] , a t t h e
Massachusetts University Medical Center in 1990. MBSR
consisted of a 2.5-h once-weekly group (including eight
members in a group) format for eight sessions. The sessions
had standard elements, including body scan exercises, men-
tal exercises focusing on the breath, physical exercises fo-
cusing on bodily sensations and own limits, and practice of
being fully aware during everyday activities by using the
breath as an anchor. To evaluate subject engagement, par-
ticipants were instructed to complete a self-report daily
monitoring form each evening to record both formal and
informal meditation practices. The MBSR sessions were
conducted by the psychiatry postgraduate resident under
the supervision of the trained psychiatrist at the
Department of Psychiatry. To do the meditation homework
while training participants in sessions, the necessary mea-
sures were listed out in a hand-out. If any of the subjects did
not participate in a session at the beginning of the next
activity, the therapist would provide written notes about it,
in addition to repeating the previous session summaries,
discuss how to keep pace with what has been developed
over the whole course, discuss plans and positive reasons
for maintaining the practice. Patients also received informa-
tion about how to detect any future relapses of the GI symp-
tom complex. The psychoeducation regarding these warn-
ing symptoms, dietary changes, and lifestyle modifications
Indian J Gastroenterol
was also reinforced to the control group, who attended
weekly sessions for the same. The study was conducted
over a period of 3 months.
Measures
The ZSDS includes 10 each positively and negatively worded
items that assess symptoms of depression. Item responses are
ranked from 1 to 4, and higher scores correspond to more
frequent symptoms. Therefore, for each item, patients give a
score according to whether the item has occurred: 1, never/very
rarely/rarely; 2, once in a while/sometime/occasionally; 3, rel-
atively often/very often/often; 4, most of the time/always/al-
most always. The scores were used to define four categories
of depression severity: within normal range or no significant
psychopathology (below 40 points); minimal to mild (40–47
points); moderate to marked (48–55 points); and severe to ex-
treme depression (56 points and above). Total scores on the
ZSDS do not correspond with a clinical diagnosis of depression
but rather indicate the level of depressive symptoms that may
be clinically relevant [23]. The FMI is a questionnaire for mea-
suring the mindfulness that the patient possesses. It consists of
14 items that cover all aspects of mindfulness. Each item is
scored on a scale of 1–4 and the items are then added to get a
summary score [24]. The MINI-Plus is a short structured diag-
nostic psychiatric interview with 120 questions that ascertains
that the diagnosis of an Axis 1 psychiatric disorder was ruled
out [25]. We used the GERD-HRQL to measure patient per-
ception of the severity of symptoms. It is a 10-question instru-
ment that examines the intensity and frequency of heartburn,
difficulty swallowing, bloating, and burden of GERD medica-
tion. Answers are graded from 1 to 5, with a maximum total
score of 50. Higher scores correspond to more severe symp-
toms and worsened health-related quality of life [26].
Recruitment challenges and attrition
Of the 211 patients interviewed for screening for eligibility, 7
declined participation and 42 were ineligible due to factors
such as previous meditation training received, comorbidities
such as diabetes, irritable bowel syndrome, and gastric ulcers
visible on endoscopy, and psychiatric disorders. Twenty-four
withdrew from the study group after one or more classes and
18 from the control group following their baseline assessment.
The reasons for withdrawal included migration to another lo-
cation, inability to attend more than 2 sessions due to family
illness, pregnancy, and work-related schedule/shift changes.
The study coordinator kept a log of logistic issues and record-
ed attendance; to facilitate the development of a consistent
daily practice of mindfulness meditation, participants were
encouraged to set aside a specific time every day for the ac-
tivity. The design of the study and the subject flow is depicted
in Fig. 1.
Indian J Gastroenterol
Statistical methods
Descriptive and inferential statistics were applied. The
Statistical Package for the Social Sciences version 23 (SPSS
23) was used for analysis and the paired t test was used to test
for statistical significance between the scores at baseline and
after 3-month follow up.
Results
Demographic characteristics
The data of a total of 120 patients,60 in the study group
and 60 in the control group were analyzed. Patients’
demographic and clinical characteristics are shown in
Table 1. The study and the control groups did not differ
significantly in terms of age, domicile, religion, educa-
tion, occupation, and socioeconomic status (Table 1).
Both the groups consisted of more male subjects, 38
(63.3%) and 34 (56.7%) in the study and control groups,
respectively. Most participants were of Hindu religion
and of a rural domicile. More than 80% of the subjects
in the study group and 70% in the control group had
been educated at least up to high school. The study
group included more unskilled workers whereas the con-
trol group had more skilled workers.
Change in level of depression with MBSR
Among 60 study participants, an initial assessment of severity
of depression symptoms using the ZSDS revealed that 27
patients (45%) belonged to a mildly depressed group and 10
(33.3%) belonged to the moderately depressed group.
Twenty-three patients (38%) had depression levels in the
Fig. 1 Design of the study and the 211 patients were
flow of the subjects screened, 7 declined
particpation and 42
were ineliigible for
inclusion.
24 withdrew from the
study group after one or
more classes.
18 withdrew from the
control group
60 patients remained in
the study group and 60
patients in the control
group
normal range and no patient in the group had severe levels
of depression. After mindfulness-based stress reduction and at
3-month follow up, 51 patients (85%) were found to be within
the normal range, 4 (6%) had moderate levels of depression
and 5 patients (8%) had scores corresponding to mild levels of
depression (p < 0.001) compared to scores before the
mindfulness-based intervention. In the control group, 37
(61.7%) had depression levels within the normal range, 16
(26.7%) had mild, and 7 (11.7%) had moderate depression
(Fig. 2). After lifestyle modification and PPI treatment in this
group, at 3-month follow up, 30 (50%) subjects belonged to
the normal range, 18 (30%) had mild and 12 (20%) had mod-
erate depression (Table 2).
Changes in the levels of distress and health-related
quality of life with MBSR
In the study group, the total GERD-HRQL scores, and
the regurgitation, and the heartburn scores reduced at 3-
month follow up as compared to that at the baseline.
The mean scores dropped from 20.5 to 12.2 (standard
deviation, SD from 9.7 to 6.8), the heartburn score from
11.3 to 5.5 (SD from 5 to 3.5), and the regurgitation
score from 8.9 to 5 (SD from 4.3 to 3.4). The differ-
ences in each of these three scores were significant
(p < 0.001). Though the difference between the total
GERD-HRQL score, and the heartburn and regurgita-
tions subscores reduced from baseline to that at 3-
month follow up in the control group as well, the dif-
ference in mean scores was of a smaller degree com-
pared with the study group (Table 3 and Fig. 3). As part
of the GERD-HRQL, along with an inquiry about the
symptoms of heartburn and regurgitation, patients were
also asked about their overall levels of satisfaction or
dissatisfaction due to the GERD-related disruption of
Consent and randomize eligible
patients
Baseline assessments with
demographics
STUDY GROUP
CONTROL GROUP
8-week MBSR course+
proton pump inhibitor Proton pump inhibitor
+lifestyle modifications +lifestyle modifications
3 months post outcome 3 months post outcome
assessment assessment
 Indian J Gastroenterol

Table 1 Sociodemographic characteristics of the study subjects reported dissatisfaction. This in contrast to the control
Demographic variables MBSR group Control group where 31 patients reported dissatisfaction even
N (%) N (%) after the intervention with lifestyle changes and PPIs
(Fig. 4).
Age (in years) 19–25 9 (15.0) 9 (15.0)
26–35 17 (28.3) 27 (45.0)
36–45 16 (26.7) 15 (25.0) Changes in levels of mindfulness
46–55 14 (23.3) 7 (11.7)
56 and above 4 (6.7) 2 (3.3)
The levels of mindfulness as measured by the FMI had a mean
total score of 30.2 (SD = 5.9) in the study group at baseline
Gender Male 38 (63.3) 34 (56.7)
evaluation; the score increased to 37.2 (SD = 4.6) after 8 week
Female 22 (36.6) 26 (43.3)
of intervention with MBSR (p < 0.001). In comparison, the
Religion Hindu 56 (93.3) 46 (76.7)
control group had a mean score of 27.5 (SD = 4.7), which
Muslim 4 (6.7) 4 (6.7)
increased to 28.3 (SD = 4.6) during the follow up period
Christian 0 (0) 6 (10.0)
(Table 3) (Fig. 5).
Others 0 (0) 4 (6.7)
Domicile Urban 26 (43.3) 17 (28.3)
Rural 34 (56.7) 43 (71.7)
Education Primary school 4 (6.7) 3 (5.0) Discussion
Middle school 7 (11.7) 11 (18.3)
High school 18 (30.0) 19 (31.7) Previous studies have shown an association between
Degree 18 (30.0) 20 (33.3) GERD and several demographic factors such as gender,
Post graduation 4 (6.7) 3 (5.0) age, educational level, and socioeconomic status [27].
Illiterate 9 (15.0) 4 (6.7) However, inconsistent results have been reported for both
Occupation Unskilled 23 (38.3) 17 (28.3) GERD prevalence rates and possible associated risk fac-
Skilled 13 (21.6) 13 (21.6) tors in different countries. These inconsistencies may be
Self employed 5 (8.3) 4 (6.6) the result of geographical variation, different lifestyle, and
Professionals 5 (8.3) 4 (6.6) methodological differences in the definition and evalua-
Private job 2 (3.3) 8 (13.3) tion of GERD symptoms.
Government job 8 (13.3) 6 (10.0) Most participants in this study were males, which is some-
Business 4 (6.6) 8 (13.3)
what similar to a few previous reports on GERD and some of
its complications such as Barrett’s esophagus and esophageal
MBSR mindfulness-based stress reduction adenocarcinoma (EAC) [28]. In our study, we did not find an
association between age and GERD. The relationship between
GERD and age is inconsistent; whereas some studies have
QOL. In the study population, 48 patients reported dis- observed a positive relationship [29] others reported an in-
satisfaction at the start of the study. After the verse association [30], and yet others did not find any associ-
mindfulness-based intervention, only 8 individuals ation [31]. The predominance of Hindus, participants from

Fig. 2 Comparison of levels of

depression in mindfulness-based
stress reduction (MBSR) and
control groups
Indian J Gastroenterol

Table 2 Comparison of levels of

depression in the mindfulness- MBSR group Control group
based stress reduction group and
control group Depression measures Pre-MBSR Post-MBSR Pre-assessment Post-assessment
N (%) N (%) N (%) N (%)

Normal range 23 (38.3) 51 (85.0) 37 (61.7) 30 (50.0)

Mildly depressed 27 (45.0) 5 (8.3) 16 (26.7) 18 (30.0)
Moderately depressed 10 (16.7) 4 (6.7) 7 (11.7) 12 (20.0)
Total 60 (100) 60 (100) 60 (100) 60 (100)

MBSR mindfulness-based stress reduction

p-value < 0.001

rural domicile, and skilled/unskilled workers could reflect the
community in and around Mysore where this study was
conducted.
To the best of our knowledge, no previous study has
assessed the role of MBSR in improving symptoms of depres-
sion in patients with GERD and its impact on QOL. The
patients included in the study did not have specific depressive
disorders but had depression symptoms on screening using the
MINI-Plus. The change in depression levels was statistically
significant indicating the value of mindfulness-based inter-
vention in these patients. Wiklund et al. evaluated psycholog-
ical factors as a predictor for treatment response in patients
with heartburn analyzing data from three prospective, ran-
domized, double-blind, placebo-controlled trials. The results
showed that high levels of depression and low vitality scores
adversely affected treatment response [32]. Kessing and col-
leagues studied 225 consecutive patients in the Netherlands
who had symptoms of GERD. Patients underwent ambulatory
24-h pH-impedance monitoring, and levels of anxiety and
depression were assessed using the Hospital Anxiety and
Depression Scale. They found that among patients with
GERD, increased levels of anxiety were associated with more
severe retrosternal pain and burning [33]. Furthermore, in-
creased levels of anxiety and depression were associated with
lower scores of the mental component of the QOL question-
naire [34].
It has been reported that all dimensions of health-related
QoL, as measured using the GERD-HRQL questionnaire,
were impaired in subjects with symptomatic GERD compared
with subjects without [10]. Those results are consistent with
the results of our study. The differences in each of the three
scores, i.e. total GERD-HRQL, heartburn, and regurgitation
scores, were found to be statistically significant. The control
group also revealed a significant difference in these scores;
however, the difference in mean scores was of a smaller de-
gree among them compared with the study group (Fig. 4). A
possible explanation for this is the lifestyle modifications and
PPI therapy which was provided to the control group as well.
However, the improvement was more pronounced in the study
group possibly because of additional MBSR. This group also
reported higher levels of satisfaction to the GERD-HRQL
compared with the control subjects possibly due to the same
reason.
Mindfulness-based therapy leads to a decrease in reactivity to
thoughts, emotions, and physical sensations, which could reduce
visceral sensitivity. The cultivation of mindfulness had led to a
reduction in the psychological distress and possible improve-
ment in emotional area activation, and cognitive dysfunction in

Table 3 Changes in
gastroesophageal reflux disease GERD-HRQL measures MBSR group Control p-value
health-related quality of life and Mean ± SD Mean ± SD
mindfulness scores
GERD-HRQL total score pre-MBSR 20.5 ± 9.7 19.9 ± 6.4 < 0.001
GERD-HRQL total score post-MBSR 12.2 ± 6.8 15.5 ± 6.8
Heartburn score pre-MBSR 11.3 ± 5.0 10.0 ± 3.4 < 0.001
Heartburn score post-MBSR 5.5 ± 3.5 7.0 ± 3.5
Regurgitation score pre-MBSR 8.9 ± 4.3 8.8 ± 2.7 < 0.001
Regurgitation score post-MBSR 5.0 ± 3.4 6.6 ± 3.1
Change in levels of mindfulness post-MBSR
Mindfulness measures pre-MBSR 30.2 ± 5.9 27.5 ± 4.7 < 0.001
Mindfulness measures post-MBSR 37.9 ± 4.6 28.3 ± 4.6

MBSR mindfulness-based stress reduction, GERD-HRQL gastroesophageal reflux disease health related quality of
life, SD standard deviation

Fig. 3 Change in
gastroesophageal reflux disease
health-related quality of life
scores
response to visceral stimuli. The decreased visceral sensitivity
could result in a reduction in the GERD symptom severity and
an improvement in QOL. Additionally, studies suggest that non-
reactivity to stimuli was associated with a reduction in pain
catastrophization, which predicts improvement in QOL and in-
creased reinterpretation of pain sensations predicted reductions
in GI symptoms [35]. To understand the potential benefits of
mindfulness in physical conditions, it may be helpful to think
about the illness experience itself. In fact, mindfulness training
enhances the emotional regulation that regulates cognition
of physical illness and thereby its symptom expression. They
ruminate on the past and worry about the future less, and engage
in less experiential avoidance of challenging situations and
difficult feelings [36]. This is possible through learning and
applying mindfulness skills, particularly at the present-
moment.
One of the limitations of the study is that the small sample
size does not enable generalization or modeling of the impact
of external variables on the trajectories of GERD-related dis-
tress and QOL. The positive outcome cannot be attributed to
Bmindfulness^ alone since other active components were part
of the therapeutic program. The information regarding various
psychosocial stressors could have affected the HRQL of the
Fig. 4 Satisfaction as per
gastroesophageal reflux disease
health-related quality of life
among mindfulness-based stress
reduction and control groups
Indian J Gastroenterol
subjects. Dietary factors, which could have influenced the
symptoms of GERD were not assessed. The compliance to
continued practice of MBSR during the follow up could not
be assessed well. Although recruitment was challenging, the
primary aim of proving feasibility was achieved. Subjects
completed the study measures in a timely fashion with fairly
good compliance.
This study demonstrated that a guided self-help mindful-
ness course was beneficial and applicable to participants who
completed the course, but requires further adaptations. This
provides exploratory evidence that mindfulness can be refined
further as an intervention for GI disorders like GERD and a
spectrum of GERD-like symptoms such as reflux symptoms,
regurgitation, heartburn, and bloating in addition to their med-
ical care. GERD is often a chronic condition and compliance
to long-term drug therapy is challenging. Approximately 25%
of GERD patients referred to pre-surgical examination are not
compliant to prescriptions, and about 40% are just partly com-
pliant [19]. The reasons for being non-compliant are, in gen-
eral, a rejection of any kind of medication use, less informa-
tion about GERD, less severity of the condition, and patients’
personality including healthcare seeking behavior. Non-
pharmacological management strategies like MBSR can
Indian J Gastroenterol
Fig. 5 Comparison of
mindfulness levels among the
study and the control groups
before and after intervention
prove to be useful in such scenarios. There is currently a pau-
city of data comparing the effectiveness of mindfulness-based
therapies to other psychological managements such as relax-
ation exercises and biofeedback. Randomized controlled trials
comparing these non-pharmacological management strategies
could prove beneficial in further quantifying the benefits of
mindfulness-based therapies. GERD can be classified as ero-
sive reflux disease (ERD) or non-erosive reflux disease
(NERD) and the prevalence of anxiety could differ between
these two groups and similarly the response to mindfulness-
based therapy, warranting an investigation. Another clinical
implication emerging from this study is the high rate of attri-
tion of participants. In clinical use, this could be reduced by
developing a briefer version. Only limited evidence is avail-
able to guide decisions about which patients are most likely to
benefit from mindfulness-based interventions.
In conclusion, symptoms of depression are common in
patients with GERD. Lifestyle modifications such as dietary
changes, elevating the head of the bed, and the use of PPIs
reduce the symptom severity and levels of distress in GERD
patients as evidenced by improvements in the control group
but the use of mindfulness-based therapy such as MBSR sig-
nificantly reduced the levels of depression in these patients.
This study further supplements the need for active collabora-
tion between gastroenterologists and psychiatrists in the use of
integrated prevention and treatment services including non-
pharmacological strategies such as mindfulness-based thera-
pies, which are likely to be a useful adjunct in treatment of
GERD.
Compliance with ethical standards
Conflict of interest SC, RR, MK, and HPN declare that they have no
conflict of interest.
Ethical clearance The authors declare that the study was performed in a
manner conforming to the Helsinki declaration of 1975, as revised in
2000 and 2008 concerning human and animal rights, and the authors
followed the policy concerning informed consent as shown on Springer.
com. Permission was obtained from the JSS Medical College and
Hospital Ethics Committee.
Disclaimer The authors are solely responsible for the data and the con-
tent of the paper. In no way, the Honorary Editor-in-Chief, Editorial
Board Members, or the printer/publishers are responsible for the results/
findings and content of this article.
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