Mindfulness intervention for mild

cognitive impairment led to

attention-related improvements and
neuroplastic changes: Results from a
9-month randomized control trial
Junhong Yu
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 Journal of Psychiatric Research 135 (2021) 203–211

Contents lists available at ScienceDirect

Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Mindfulness intervention for mild cognitive impairment led to

attention-related improvements and neuroplastic changes: Results from a
9-month randomized control trial
Junhong Yu a, *, Iris Rawtaer b, Lei Feng a, Johnson Fam a, Alan Prem Kumar d,
Irwin Kee-Mun Cheah e, William G. Honer f, Wayne Su f, Yuan Kun Lee g, Ene Choo Tan h, i,
Ee Heok Kua a, Rathi Mahendran a, c, **
a
Department of Psychological Medicine, Mind Science Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b
Department of Psychiatry, Sengkang General Hospital, Singhealth Duke-Nus Academic Medical Centre, Singapore
c
Academic Development Department, Duke-NUS Medical School, 8 College Road, Singapore
d
Cancer Science Institute of Singapore, National University of Singapore, And Medical Science Cluster, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore
e
Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
f
Department of Psychiatry, University of British Columbia, Vancouver, Canada
g
Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University Hospital, Singapore
h
KK Research Laboratory, KK Women’s and Children’s Hospital, Singapore
i
SingHealth Duke-NUS Paediatrics Academic Clinical Program, Singapore

A R T I C L E I N F O A B S T R A C T

Keywords: Mindfulness-based interventions can enhance cognitive abilities among older adults, thereby effectively delaying
Mindfulness cognitive decline. These cognitive enhancements are theorized to accompany neuroplastic changes in the brain.
Meditation However, this mindfulness-associated neuroplasticity has yet to be documented adequately. A randomized
RCT
controlled trial was carried out among participants with mild cognitive impairment (MCI) to examine the effects
Cognitive enhancement
Attention
of a mindfulness-based intervention on various cognitive outcomes and cortical thickness (CT) in the context of
Cortical thickness age-related cognitive impairment. Participants were assigned to a mindfulness awareness program (MAP)(n =
Neuroplasticity 27) and an active control condition — health education program (n = 27). In both, they attended weekly sessions
Mild cognitive impairment for three months and subsequently, monthly sessions for six months. Cognitive assessments and structural scans
were carried out across three time-points. Whole brain analyses on CT were carried out and were supplemented
with region of interest-based analyses. ROI values and cognitive outcomes were analyzed with mixed MANOVAs
and followed up with univariate ANOVAs. Nine-month MAP-associated gains in working memory span and
divided attention, along with an increased CT in the right frontal pole and decreased CT in the left anterior
cingulate were observed. Three-month MAP-associated CT increase was observed in the left inferior temporal
gyrus but did not sustain thereafter. MAP led to significant cognitive gains and various CT changes. Most of these
neurobehavioral changes, may require sustained effort across nine months, albeit at a reduced intensity. MAP can
remediate certain cognitive impairments and engender neuroplastic effects even among those with MCI.

1. Introduction outcomes and functional independence (Gauthier, 2005). To this end,

the mild cognitive impairment (MCI) diagnostic entity conceptualized
Early treatment in dementia is crucial to maximizing treatment two decades ago, has been positioned as the intermediate stage between

* Corresponding author. Department of Psychological Medicine Yong Loo Lin School of Medicine, National University of Singapore MD1 Research Dry Laboratories
(North), #12-01, 12 Science Drive 2, 117549, Singapore.
** Corresponding author. Senior Consultant and Associate Professor, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University
of Singapore, NUHS Tower Block, Level 9, 1E Kent Ridge Road, 119228, Singapore.
E-mail addresses: pcmyj@nus.edu.sg (J. Yu), pcmrathi@nus.edu.sg (R. Mahendran).

https://doi.org/10.1016/j.jpsychires.2021.01.032
Received 21 February 2020; Received in revised form 23 December 2020; Accepted 16 January 2021
Available online 21 January 2021
0022-3956/© 2021 Elsevier Ltd. All rights reserved.
J. Yu et al.
Fig. 1. Consort flow diagram. MCI = mild cognitive impairment; MRI = magnetic resonance imaging; MAP = Mindfulness Awareness Program; HEP = Health
Education Program; AX = assessment.
healthy aging and dementia, in which researchers are optimistic that
interventions would alter the course of subsequent cognitive decline
(Petersen et al., 2014).
Among the non-pharmacological interventions that have been car­
ried out on the MCI population, there has been a growing interest in
mindfulness-based interventions (Chan et al., 2019). Although such in­
terventions traditionally target psychoaffective or behavioral issues
(Baer, 2003), evidence suggests that they can bring about a strong
cognitive enhancement effect (Chiesa et al., 2011) as well— which can
be exploited to delay subsequent cognitive decline. This is due to the fact
that meditation recruits several cognitive processes, which are trained
upon repeated sessions.
Mindfulness meditation generally involves focused attention and/or
open monitoring. In focused attention, the meditator has to direct and
sustain attention on an internal or external stimulus for a period of time.
In doing so, the meditator needs to constantly monitor his/her thoughts
to detect mind wandering. Occasionally, the meditator disengages from
204
Journal of Psychiatric Research 135 (2021) 203–211
a distracting object (attention switching) and redirects attention to
another stimulus (selective attention)(Lutz et al., 2008). During open
monitoring, the meditator attends to the moment-by-moment experi­
ence in the ‘here and now’ in a nonjudgmental manner. In doing so,
he/she has to inhibit automatic cognitive appraisals and divert attention
away from distracting stimuli that would obscure attention to the
moment-by-moment experience (Jha et al., 2019). Essentially, medita­
tion can be thought of as a type of cognitive training for these different
cognitive abilities.
Alongside these training-related improvements, repeated sessions of
meditation may also trigger experience-dependent neuroplastic
changes. In this regard, one randomized controlled trial (RCT) assigned
healthy participants (i.e., self-reported to be psychologically and phys­
ically healthy, and not taking any medications) to a nine-session
Mindfulness-Based Stress Reduction (MBSR n = 16) intervention or a
wait-list control condition (n = 17) and compared the gray matter (GM)
changes between both groups. It was observed that the GM volumes in
J. Yu et al. Journal of Psychiatric Research 135 (2021) 203–211

Table 1 2. Material and methods

Characteristics of participants assigned to both treatment conditions.
MAP (N = HEP (N = Between-group 2.1. Design
27) 27) comparison

t χ2 p The study was carried out as an open-label RCT. Randomization was

stratified by gender and carried out in blocks of four using the Random
Mean age (SD) 71.3 (5.6) 71.4 (6.0) .12 .91
Sex
Allocation Software 2.0 by an independent researcher. The intervention
Male 8 6 .39 .54 consisted of two arms— mindfulness awareness program (MAP) and
Female 19 21 health education program (HEP). The latter was used as an active con­
Mean years of education (SD) 5.2 (4.9) 3.4 (4.3) 1.39 .17 trol condition for the former, to control for possible effects due to social
Mean MMSE score (SD) 24.6 (3.3) 24.7 (3.9) .11 .91
interaction. The intervention spans across nine months and consisted of
Mean sessions attendeda (SD)
First 3 months (12 sessions) 10.6 (1.5) 10.8 (1.4) .30 .77 two phases in both arms. During the first 3-month phase, sessions were
Subsequent 6 months (6 5.2 (1.5) 5.3 (1.2) .9 .93 held once per week for 12 sessions. Thereafter, these sessions took place
sessions) once per month in the subsequent 6-month phase. The rationale for
Note. MAP = Mindfulness awareness program; HEP = Health education pro­ dividing the intervention into two different phases of different treatment
gram; SD = standard deviation; MMSE = Mini-Mental State Examination. intensities was to assess if the treatment gains from the first phase can be
a
Among the analyzed longitudinal sample. sustained with much less time commitment from the participants in the
second phase. Each session would last for 45 min. The CONSORT flow
diagram of the study is shown in Fig. 1. Ethical approval for the current
Table 2 study was granted by a university’s institutional research board.
Cognitive outcomes assessed.
Test Outcomes Cognitive functions assessed 2.2. Participants
Semantic fluency test Number of unique Verbal fluency
animals Participants of the current study were recruited from the community,
Color trails test Interference effect Divided attention and set- as part of the larger Aging in a Community Environment Study cohort
switching (Feng, 2015). Details regarding the recruitment, which was carried out
Digit span subtests (WAIS- Digits forward total Working memory span
III) score
from 2011 to 2016 have been described elsewhere (Yu et al., 2016).
Digits backward total Working memory Subsequently, participants from this cohort were invited to participate
score manipulation in the current intervention study. The inclusion criteria were 1) aged
Rey Auditory Verbal Immediate recall Immediate memory between 60 and 85 (inclusive), 2) met the criteria for mild cognitive
Learning Test Delayed recall Delayed memory
impairment (MCI), 3) able to travel to the intervention venue indepen­
Delayed recognition Recognition memory
Block design test (WAIS- Total raw score Visuospatial processing dently, 4) not presenting with any current psychiatric or neurological
III) conditions, 5) not suffering from any terminal illness, 6) not partici­
pating in another interventional study and 7) for those undergoing
Note. WAIS-III = Wechsler Adult Intelligence Scale III.
magnetic resonance imaging (MRI) scans, not having any metallic body
implants (e.g., pacemaker), with the exception of dental implants.
left posterior cingulate cortex, left temporo-parietal junction, hippo­
The Petersen’s (2004) criteria were used for the MCI diagnosis. These
campus and bilateral regions in the cerebellum had increased in the
include subjective cognitive complaints as corroborated by a reliable
MBSR group as compared to the wait-list controls (Hölzel et al., 2011).
informant, presence of objective cognitive impairment and largely pre­
Another RCT (Pickut et al., 2013) compared 14 patients with Parkin­
served functional independence. In particular, the objective cognitive
son’s disease assigned to an eight-week mindfulness-based intervention
impairment criterion was operationalized as scoring 1.5 standard de­
and 13 patients on usual care, and found increased GM volume in the
viations (SD) below the age and education appropriate norms in any of
bilateral caudate nucleus, left occipital lobe, left thalamus and bilateral
six cognitive domains, as assessed via the digit span backward and block
temporo-parietal junction in the former group. A third RCT compared 12
design tests from Wechsler Adult Intelligence Scale (WAIS-III), delayed
college students assigned to a 4-week Sahaja Yoga meditation training
recall and recognition tests from the Rey Auditory Verbal Learning Test
with 30 wait-list controls and found meditation-associated GM increase
(RAVLT), Color Trails Test (CTT), and semantic fluency test. The MCI
in the right inferior frontal gyrus (Dodich et al., 2019). Additionally, two
diagnoses were made via a consensus from a panel of psychiatrists and
other RCTs (Tang et al., 2010; Wells et al., 2013) did not observe sig­
psychologists.
nificant meditation-associated GM changes. In general, the evidence on
Fifty-four participants were randomized into the two treatment
the neuroplastic GM changes associated with meditation has been
conditions. Information regarding their demographic characteristics,
limited and inconclusive.
general cognitive status and attendance are presented in Table 1. Inde­
In addition to replicating the previously documented meditation-
pendent samples t-tests suggest that both intervention groups were not
associated cognitive gains, we sought to make a meaningful contribu­
significantly different in terms of attendance in the two phases (ps ≥
tion to the limited pool of evidence relating to the meditation-associated
.77). Written informed consent was obtained from these participants
neuroplasticity. The current study evaluates the effect of a mindfulness-
prior to their participation. Among them, 51 had at least completed the
based intervention on various cognitive outcomes and GM cortical
first 3-month phase and 39 completed both phases. For the first three
thickness (CT) across a 9-month intervention period. We hypothesized
months, our calculations using G*Power indicated that the valid sample
that such intervention would engender significant cognitive gains,
size would provide a power of 0.80 (assuming an alpha level of 0.05 and
especially in the attentional domains, as well as increase CT in various
a 0.5 correlation between repeated measures) to detect a significant
cortical GM regions which were found to differ between experienced
Time * Group interaction if the true effect was at least 0.40 SD. Across
meditators and meditation-naïve controls.
the entire 9-month intervention period, our calculations using the same
parameters suggest that we can detect a true effect of at least 0.46 SD.
Considering that a recent meta-analysis (Chan et al., 2019) revealed a
much larger effect of meditation on global cognition among older adults
(SMD = 0.56), our sample sizes are more than adequate to detect the
hypothesized interaction effect on cognitive outcomes.

205
J. Yu et al. Journal of Psychiatric Research 135 (2021) 203–211

Table 3
Results of the mixed ANOVA on cognitive outcomes from baseline to ninth month.
Cognitive outcome Time Group Time * Group

F p F p F p q η2partial
Digit span forward 3.50 0.069 0.01 0.914 8.01 0.007 0.060 0.18
Digit span backward 0.61 0.438 0.90 0.348 1.85 0.182 0.484 0.05
Immediate recall 7.00 0.012 3.65 0.064 0.40 0.533 0.849 0.01
Delayed recall 10.48 0.003 3.87 0.057 0.09 0.770 0.849 <.01
Recognition <.01 0.960 2.72 0.107 0.04 0.849 0.849 <.01
CTT - interference 1.58 0.217 3.03 0.091 5.03 0.031 0.126 0.13
Block design 11.17 0.002 2.27 0.140 0.28 0.600 0.849 <.01
Semantic fluency 0.91 0.348 0.47 0.495 0.12 0.732 0.849 <.01

Note. CTT = Color trails test; q = p values adjusted for false discovery rate.

2.3. Measures
Eight cognitive outcomes, indexing working memory span and
manipulation, divided attention, immediate, delayed and recognition
memory, verbal fluency and visuospatial processing from various tests
were administered (see Table 2). The procedures for these tests are
described in detail in the supplementary materials. For these measures,
higher scores correspond to better performance, with the exception of
the CTT interference, in which smaller interference scores relate to
better performance.
2.4. Intervention protocol
The MAP was modeled on similar group-based mindfulness medita­
tion for older adults (McBee, 2008) and was led by an experienced
instructor. Participants were taught 1) mindfulness of the senses
practice— to attend to the different senses (i.e., vision, hearing, touch)
to cultivate focused attention; 2) body scan practice— to develop kin­
esthesia by focusing their attention on various parts of their body as a
relaxation technique, while in a sitting and/or supine position; 3)
walking meditation practice— to cultivate calmness and momentary
concentration by walking slowly with mindfulness; 4) ‘movement nature
meant’ practice— to move with awareness for flexibility, strength and
confidence; and 5) visuomotor limb tasks that train one’s mind-body
coordination.
The weekly HEP didactic sessions were taught by an experienced
instructor, and covered topics such as chronic medical conditions (e.g.,
hypertension, diabetes, arthritis), medication compliance, and healthy
lifestyles (e.g., diet, nutrition, exercise, and relaxation). In the subse­
quent monthly discussion sessions, participants shared how they had
applied what they learned to their daily lives. Both programs were
separately carried out in a quiet room in a community location.
2.5. MRI acquisition
Participants were scanned in a 3-T Siemens Tim Trio scanner at the
Clinical Imaging Research Center, Singapore. T1-weighted images were
acquired using an MPRAGE protocol (TE = 1.90s; TR = 2.30s; TI = 900
ms; 256 × 256 matrix; 192 sagittal slices; in-plane resolution = 1 mm;
slice thickness = 1 mm).
2.6. Image preprocessing
T1-weighted images were preprocessed longitudinally using the
CAT12 (version r1450) as implemented in SPM12 (version 6225) within
MATLAB (R2019a). Baseline and follow-up images were rigidly real­
igned within-subject to correct for differences in head position and a
subject-specific average template was computed and used as reference in
a subsequent realignment of the baseline and follow-up images. The
realigned images were segmented into GM, white matter (WM) and
cerebrospinal fluid, as well as corrected for signal inhomogeneities with
reference to the subject average template. These GM and WM images
were used to estimate spatial normalization deformation fields using the
high dimensional Diffeomorphic Anatomic Registration Through Expo­
nentiated Lie Algebra (DARTEL) warping algorithm (Ashburner, 2007)
which were applied to segmented images and subsequently modulated.
These modulated images were then visually inspected.
Estimation of CT and the central surface was carried out using the
projection-based thickness method (Dahnke et al., 2013), which con­
sisted of topology correction (Yotter et al., 2011), spherical mapping,
and spherical registration (Yotter et al., 2011). After obtaining the
segmented images, WM distance was estimated and the local maxima
were projected to other GM voxels using a neighbor relationship
described by the WM distance (Dahnke et al., 2013). The ‘surface
thickness and thickness estimation for ROI’ writing option was used to
extract region-of-interest (ROI) values from the Desikan-Killiany atlas
(Desikan et al., 2006).
2.7. Statistical analyses
We were primarily interested in the treatment gains at the two
possible ‘exit points’ —third and ninth month, hence for the following
analyses we compared the outcomes between baseline and third month,
as well as between baseline and ninth month timepoints.
First, we carried out whole brain analysis on the preprocessed sur­
faced images. Two subjects (one from each treatment group) were
excluded from these analyses due to significant lesions. Then, treatment
effects were assessed using a flexible factorial GLM, modeling the three
factors of Subject, Group and Time, in which we examined the T con­
trasts for the Group * Time interaction (i.e., Timepost > Timepre & MAP
> HEP and Timepost > Timepre & MAP < HEP). The results were
thresholded using p < 0.05, family-wise error (FWE) correction against a
null-distribution generated by 5000 nonparametric permutations using
the TFCE toolbox, with a cluster extent threshold of k > 20. Significant
clusters are labeled using the Desikan-Killiany atlas.
Given the relatively small number of scanned participants, a whole
brain analysis was unlikely to yield multiple clusters that would survive
the stringent FWE corrections. Hence, we supplemented the whole brain
analyses with ROI-based analyses. Specifically, we selected on an a
priori basis, ROIs that corresponded to the significant cortical GM
clusters identified in a meta-analysis that compared between experi­
enced meditators and meditation naïve controls (Fox et al., 2014). These
included the bilateral regions of the anterior cingulate cortex (ACC),
orbitofrontal cortex (OFC), frontal pole (FP) and insula. Apart from the
first two, these ROIs were extracted as they were parcellated in the atlas.
The ACC ROI was created by summing the caudal and rostral anterior
cingulate ROIs, and the OFC ROI was created by summing the lateral and
medial orbitofrontal ROIs. These ROIs were entered into subsequent
analyses together with the cognitive outcomes.
For the analyses of the cognitive outcomes and CT ROIs, in order to
minimize the false positive results associated with multiple testing,
multivariate analyses of variance (MANOVA) were carried out sepa­
rately on the cognitive outcomes and CT ROIs, with time and group as
the within- and between-subject factors, respectively, to determine the

206
J. Yu et al.
Fig. 2. Trajectories of cognitive outcomes in each group across time. The thick colored lines represent the mean trajectory of each group, which are enclosed within
their respective 95% confidence intervals. *p < .05; **p < .01.
overall effect on the assessed outcomes. In line with our general
analytical framework, the MANOVAs compared between baseline and
third month, as well as between baseline and ninth month timepoints. If
significant group*time interaction effects were obtained in any of these
MANOVAs, post hoc univariate analyses of variance (ANOVA) were
carried out individually on each outcome between the respective time­
points. Although it is possible to analyze all three timepoints in a single
MANOVA and proceed with post hoc analyses, we did not do so. This is
because the valid sample size at the ninth month timepoint is much
smaller, given that the three-timepoint MANOVA can only be carried out
207
Journal of Psychiatric Research 135 (2021) 203–211
on participants with valid data on all three timepoints, such analyses
would discard several participants with incomplete ninth month data,
ultimately reducing statistical power. Effect sizes for the significant
statistics relating to the time * group interactions were quantified using
partial eta square (η2partial), where η2partial of 0.06 and 0.13 indicates
medium and large effect sizes, respectively. Statistical significance was
set at p < .05. For the post-hoc ANOVAs, we have additionally computed
p-values adjusted for false discovery rate (FDR). Nevertheless, we do not
expect the significant results of these ANOVAs to survive such correc­
tions, as this would require very large treatment effects and sample sizes
J. Yu et al.
Table 4
Results of the mixed ANOVA on the regions-of-interest from baseline to ninth month.
Regions-of-interest Time Group
F p F p
Anterior cingulate L 0.20 0.658 0.13
Anterior cingulate R 0.01 0.924 0.01
Orbitofrontal L 0.52 0.479 0.02
Orbitofrontal R 0.91 0.351 0.11
Frontal pole L 0.92 0.349 0.68
Frontal pole R 0.15 0.704 0.01
Insula L 1.63 0.217 0.08
Insula R 3.44 0.079 0.22
Note. L = Left; R = Right; q = p values adjusted for false discovery rate.
that are beyond what is expected or practical for this study. These an­
alyses were carried out R 4.0.2. The R code for executing these analyses
and generating the figures are available at https://osf.io/ykz2c/files/.
3. Results
3.1. Effect of MAP on cognitive outcomes
The MANOVAs revealed a significant Time * Group effect on
cognitive outcomes between the baseline and ninth month (F(8, 28) =
1.92; p = .022; η2partial = 0.44),but not between baseline and third month
(F(8, 39) = 1.92; p = .106; η2partial = 0.27). Thus, univariate ANOVAs
were carried out to follow up on the significant effects between the
baseline and ninth month. The detailed results of all modeled effects in
these ANOVAs are presented in Table 3. In these post hoc analyses,
significant Time*Group interactions emerged for digit span forward and
CTT interference. Fig. 2 showed that the digit span forward score and
CTT interference among MAP participants had increased and decreased,
respectively over time, relative to their HEP counterparts. As expected,
none of these significant post-hoc results survived the FDR correction.
3.2. Effect of MAP on cortical thickness
The MANOVAs on the CT revealed a significant Time * Group effect
between baseline and ninth month (F(8, 12) = 3.03; p = .041; η2partial =
0.67), but not between baseline and third month (F(8, 29) = 2.01; p =
.080; η2partial = 0.36). Univariate ANOVAs were carried out to follow up
on the significant effects between baseline and ninth month. The
detailed results of all modeled effects in these ANOVAs are presented in
Table 4.These ANOVAs revealed a significant Time * Group on the right
FP (F(1, 19) = 5.19; p = .035; η2partial = 0.21) and left ACC (F(1, 19) =
5.18; p = .035; η2partial = 0.21). Fig. 3 showed that, relative to HEP
participants, the CT in the right FP and left ACC among MAP participants
had increased and decreased, respectively, across this period. None of
these significant post-hoc results survived the FDR correction. Addi­
tionally, none of the CT changes in any ROIs were significantly corre­
lated with any of the changes in cognitive outcomes. The descriptive
statistics of the ROI CT values across the three time-points are reported
in the supplementary materials (see table S2).
Next, CT was analyzed at the whole brain level. Across the first three
months, whole brain analyses within the contrast of Time3-month >
Timebaseline & MAP > HEP revealed a significant cluster in the left
inferior temporal gyrus (ITG)(k = 28, peak level FWE-corrected p =
.009; MNI = − 55, − 33, − 24; see Fig. 4a). No significant clusters
emerged in the reverse contrast (i.e., Time3-month > Timebaseline & MAP
< HEP). Across the entire 9-month intervention period, no significant
clusters were observed in any of the interaction contrasts. The uncor­
rected statistical maps of these contrasts are presented in the supple­
mentary materials (see figures S1 and S2). Given these results, there is a
possibility that the significant cluster obtained from the first 3-month
period did not appear in the subsequent 6-month period, merely due
to the reduced sample size. Hence, we investigated this further by
208
Journal of Psychiatric Research 135 (2021) 203–211
Time * Group
F p q η2partial
0.718 5.18 0.035 0.138 0.21
0.913 0.01 0.921 0.921 <.01
0.898 0.04 0.848 0.921 <.01
0.747 0.80 0.381 0.844 0.04
0.419 0.03 0.855 0.921 <.01
0.936 5.18 0.035 0.138 0.21
0.784 0.16 0.695 0.921 <.01
0.647 0.67 0.422 0.844 0.03
extracting the significant cluster as an ROI and entering these ROI values
into a mixed ANOVA. The Time * Group effect across the entire 9-month
intervention period was not significant (F(1, 36) = 0.21; p = .649;
η2partial = 0.01 see Fig. 4b), in contrast to the significant interaction across
the first three months (F(1, 19) = 23.27; p < .001; η2partial = 0.39).
4. Discussion
The current study examined the effects of a mindfulness-based
intervention on cognitive outcomes and CT. In the cognitive domain,
we observed a gradual improvement in working memory span and
divided attention among MAP participants relative to their HEP coun­
terparts, culminating in medium to large effect sizes across the entire 9-
month intervention period. As for CT, MAP participants, relative to their
HEP counterparts had significantly increased CT, as quantified by a large
effect size, in the right FP across the entire 9-month intervention period.
At the end of the first 3-month phase, the CT in MAP participants had
significantly increased in a left ITG cluster, as quantified by a large effect
size, relative to HEP participants. However, these 3-month MAP-
associated CT changes in the left ITG did not sustain until the ninth
month. Overall, these results suggest that the MAP intervention led to
significant cognitive gains and neuroplastic changes across the 9-month
intervention period.
With repeated sessions of meditation, our MAP participants trained
their abilities to engage and disengage their attention on various stimuli.
Naturally, the effect of such attentional training would transfer to our
measure of divided attention, where participants had to repeatedly
engage and disengage between two sets of stimuli (i.e., pink and yellow
circles in the CTT). Furthermore, we observed MAP-associated working
memory improvements as measured by the digit span forward. Gener­
ally, working memory span benefits from an improved attention. A
larger working memory span can be the result of a greater ability to
control attention to avoid distraction and thereby maintain more stored
items (Engle, 2002). Such controlled attention was practiced in our MAP
as participants focused and sustained their attention on various external
and interoceptive stimuli. However, we did not observe a similar
MAP-associated improvement for working memory manipulation as
measured by the digit span backward. Although meditation typically
involves the manipulation information in the working memory, such
manipulation is largely restricted to the engagement and disengagement
of information in the present moment without judgment or elaboration
(Jha et al., 2019). Arguably, this involves a relatively low cognitive load.
Our measure of working memory manipulation requires elaborate pro­
cessing of information— to reverse the order of the digits while holding
these digits in the working memory. Essentially, for the digit span
backward, working memory is being tested while being weighed down
by an additional cognitive load. This is not something our MAP partic­
ipants would have had more practice with than their HEP counterparts.
In terms of MAP-associated neuroplasticity, we observed some CT
changes which are consistent with previous findings. First, there was a
significant MAP-associated increase in the CT of the left ITG (at least
within the first three months) and right FP. A meta-analysis (Fox et al.,
J. Yu et al.
Fig. 3. Trajectories of cortical thickness values in each group across time. The thick colored lines represent the mean trajectory of each group, which are enclosed
within their respective 95% confidence intervals. *p < .05.
2014) that compared between experienced meditators and medi­
tation-naïve controls had observed similar clusters of GM volume in­
crease in the right frontopolar cortex (including the FP) and left ITG.
Relatedly, task-based functional MRI studies have shown that activa­
tions in the frontopolar cortex (Molenberghs et al., 2016) and the left
ITG (Hasenkamp et al., 2012) were linked to meditation-associated
meta-cognitive processes, such as meta-cognitive judgments and
awareness of mind wandering. Given this, the MAP-associated CT in­
creases in these regions could speculatively be linked to the enhanced
meta-cognitive abilities typically brought about via repeated sessions of
209
Journal of Psychiatric Research 135 (2021) 203–211
meditation. As our intervention transitioned from weekly to monthly
sessions, it was observed that the increased CT in the left ITG, were no
longer sustained at the ninth month. Perhaps, this suggests that the
monthly meditation sessions were not adequate to maintain such gains.
It is plausible that if our intervention had continued its weekly sessions,
greater neuroplastic changes and perhaps cognitive gains would be
observed. Indeed, a meta-analysis on mind-body exercises observed that
interventions with more frequent sessions were more likely to result in
greater cognitive gains than those of less frequent sessions (Chan et al.,
2019).
J. Yu et al.
Fig. 4. a) Significant cluster (FWE-corrected p < 0.05) in left inferior temporal gyrus within the contrast of Time3-month > Timebaseline & MAP > HEP. b) trajectories
of cortical thickness values of extracted cluster in each group across time. The thick colored lines represent the mean trajectory of each group, which are enclosed
within their respective 95% confidence intervals. ***p < .001.
In contrast to previous cross-sectional studies that found increased
ACC GM volume among experienced meditators (Fox et al., 2014), we
observed a MAP-associated CT decrease in the ACC. Notwithstanding,
the problems of comparing the current intervention results to
cross-sectional findings, this decrease in ACC CT or volume should not
always be viewed negatively, especially since the ACC is involved in
several functions. One such function includes emotional processing
(García-Cabezas and Barbas, 2016). In relation to this, a lesion study
(Tolomeo et al., 2016) suggests that the removal of the anterior cingu­
late may be therapeutic for patients with intractable mood, anxiety and
pain syndromes, specifically in terms of reducing negative affect.
Relatedly, we speculate that the reduced ACC CT among MAP partici­
pants may reflect the neuroplastic changes corresponding to the
MAP-associated attenuations in emotional reactivity to negative affect
(Britton et al., 2012).
These findings present important implications in the clinical context.
We have shown that a relatively low intensity (i.e., weekly or monthly
sessions) non-pharmacological intervention can result in significant
cognitive gains and neuroplastic changes in the context of age-related
cognitive impairment. In essence, our intervention would be instru­
mental in delaying further cognitive decline or even enhancing one’s
functional status, without the side-effects of medications (Smith, 2016)
or exhaustion associated with intensive cognitive training (Vranic,
2017). Additionally, the MAP-associated cognitive gains were mostly
observed within the domains of executive-attention. This would suggest
that such mindfulness-based interventions would be more appropriate
for older adults with executive-attentional impairments, such as those
with nonamnestic MCI or at risk for frontotemporal dementia, than
those with amnestic MCI or at risk for Alzheimer’s disease. It should also
be noted that while the targeted cognitive gains are most relevant to this
group of older adults, their executive functions deficits may bring about
some difficulties during meditation, especially when they are required to
sustain and focus their attention for a period of time.
The current study is subjected to a few limitations. First, this was an
open-label study, in which both participants and the experimenters were
aware of which treatment group the former was assigned to. There is a
small possibility that the results may be confounded by observer-
expectancy effects among experimenters and the differences in partici­
pants’ treatment expectancies between both groups. Second, the attri­
tion rate for MRI data was quite significant; by the ninth month, the
number of acquired scans was less than half of that at baseline. This
limits the study’s ability to detect significant treatment effects on CT
during the subsequent 6-month phase. Given that this attrition was
largely due to various physical and psychological discomforts during the
scans, future studies should attempt to alleviate some of these
210
Journal of Psychiatric Research 135 (2021) 203–211
discomforts in order to retain as many MRI-eligible participants as
possible, especially among the older adult population.
CRediT authorship contribution statement
Junhong Yu: Writing - original draft, Formal analysis, Software,
Visualization. Iris Rawtaer: Writing - original draft. Lei Feng: Writing -
review & editing. Johnson Fam: Writing - review & editing. Alan Prem
Kumar: Formal analysis, Writing - review & editing. Irwin Kee-Mun
Cheah: Writing - review & editing. William G. Honer: Writing - re­
view & editing. Wayne Su: Software, Formal analysis, Writing - review
& editing. Yuan Kun Lee: Writing - review & editing. Ene Choo Tan:
Writing - review & editing. Ee Heok Kua: Writing - review & editing,
Funding acquisition. Rathi Mahendran: Writing - review & editing,
Funding acquisition, Project administration, Supervision.
Declaration of competing interest
None.
Acknowledgement
We acknowledge the contributions of the following: the Late Mr Wee
Sin Tho for developing and structuring the Mindfulness Program for this
study and Dr Goh Lee Gan for developing and delivering the Health
Education Talks
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpsychires.2021.01.032.
Financial support
This work was supported by Research Donations from Kwan Im
Thong Hood Cho Temple and Lee Kim Tah Holdings Pte Ltd under the
Mind Science Center, Department of Psychological Medicine, National
University of Singapore.
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Another random document with
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 Along the shore of the sounding sea they went, making prayer to
Zeus that he would grant them success in what they sought.
When they came to the ships and huts of Achilles they found him
sitting with a lyre in his hand. Of beautiful workmanship it was, with a
silver cross-bar upon it, and as the hands of Achilles drew from it
wondrous melody, he sang of the glorious deeds of the heroes of
old.
Beside him sat Patroclus, listening silently to the song of the
friend that he loved.
Then did Odysseus step forward, and Achilles, amazed, sprang
to his feet, his lyre in his hand, and Patroclus also arose.
‘Welcome ye are,’ said Achilles; ‘truly ye are friends that are
come. Even in my anger are ye the dearest of all the Greeks to me.’
Then he led them forward and made them sit on seats covered
with lordly purple.
To Patroclus he said:
‘Bring forth the biggest bowl and the finest of my wines, for I have
no dearer friends than those who are here with me now.’
So did Achilles have a rich feast of precious wines and of dainties
of all sorts made ready for those who brought him the message of
Agamemnon the king.
And when the feast was ended, Odysseus did tell him of the dire
woes of the Greeks and of the royal gifts of Agamemnon, and of the
pleadings of the Greeks and of their overlord, that their hero,
Achilles, would come and fight for them once again.
Then did Achilles make answer:
‘Hateful to me as are the gates of death, O great Odysseus, is
the man who hideth in his heart one thing and sayeth another. So will
I speak to thee as seemeth me best. Hard have I laboured, fiercely
have I fought for Agamemnon, yet what is my gain after it all?
Hateful to me are the gifts of Agamemnon. Wealth and power can be
mine without aid from him, yet know I well, for my mother, Thetis the
silver-footed, hath told me, that death swiftly draweth nigh. Let the
Greeks seek help elsewhere, for fierce is my anger, and no help
shall ye gain from me.’
Then said Ajax:
‘Let us go hence, Odysseus. Our embassy is vain. Yet evil though
the news we carry with speed must we bear it back to the Greek
host. Merciless art thou, Achilles! Anger hath made thee set at
naught thy comrades’ love and the love of thine own dear land.’
And to Ajax did Achilles make answer:
‘Take ye, then, my message, brave Ajax! Tell Agamemnon that
until the day that the men of Troy come even to my ships and my
huts and smirch them with fire, no finger will I raise for Greece. But
on that day, then, surely, will the power of the Trojans be stayed.’
Then did Odysseus and Ajax and the others return in sorrow to
the host of the Greeks, and gave to them the message of Achilles.
In silence did the warriors listen.
Then said Diomedes:
‘Achilles, then, must bide his time. When his heart is aroused
again within him, he will fight. But let us now take meat and drink and
sleep, and when rosy-fingered Dawn doth come, strength shall be
ours for the battle, and with courage shall we fight for the cause of
Agamemnon our king!’
 CHAPTER IX
THE WHITE HORSES OF RHESUS

Sound was the sleep of the Greek chiefs that night, but Agamemnon
the king slept not. From his enemies’ camp came the sound of pipe
and flute and laughter of men, as the Trojans feasted and made
merry in the red light of their camp-fires. As he looked seawards at
the ships of the sleeping Greeks, his heart was heavy within him and
he groaned aloud.
On his feet he bound his sandals, over his shoulders did he throw
his great mantle of a tawny lion’s skin, and, grasping his spear, he
went forth into the night to take counsel of wise Nestor.
Neither to Menelaus came there sleep, for his heart was full of
fear lest harm should come to the Greeks who had crossed the wide
seas to fight for his sake in Troyland.
 Agamemnon heard the sound of pipe and flute and laughter of men as
the Trojans feasted and made merry (page 86)

On his head he placed his bronze helmet, across his broad

shoulders he threw a leopard skin, and, spear in hand, went to seek
his brother.
Down by the ships he found him, putting his armour on.
‘Why dost thou arm thyself, dear brother?’ he asked. ‘Wilt thou
send forth one of our comrades to spy on the Trojans? I fear me no
man of ours is of courage enough to go alone in the night and do so
brave a deed.’
 Then did Agamemnon bid his brother go and awake the lords of
his host and call a council together, while he himself went to rouse
Nestor, the oldest of all the warriors.
And as they passed through the host they found the sentinels
sitting wide awake with their arms, like dogs that watch by a lonely
sheepfold amongst the hills and listen to the cries of the savage wild
beasts that come towards them through the woods.
Gladly did old Nestor see them.
‘Even so keep watch, dear children,’ he said, ‘lest we allow our
enemies to triumph over us.’
Out in the open field, beyond the deep trench which they had
dug, the chiefs of the Greeks sat themselves down in council.
To them, then, spake Nestor.
‘O friends,’ said he, ‘is there among you a man with heart so
fearless that all alone he will go into the camp of the Trojans this
night and there learn what are their plans for battle? If such an one
there be, and he return to us scathless, great will be his fame among
all men, and great the rewards that he wins.’
Then said Diomedes of the loud war-cry:
‘With willing heart will go, Nestor: yet if another man will come
with me, more comfort and courage will be ours.’
Many there were who asked with eagerness to be that one who
should go with Diomedes. But Agamemnon spoke.
‘Diomedes, joy of mine heart, verily shalt thou choose thine own
comrade,’ he said.
And Diomedes made answer:
‘If indeed I may choose, then shall I choose Odysseus, for with
him as comrade we might pass through raging flames and yet return
in safety.’
 ‘Praise me not overmuch, Diomedes,’ said Odysseus, ‘but let us
be going. The night wanes, the stars have gone onward, and the
dawn is near.’
Then did they don their armour, and set forth, like two lions
seeking their prey, treading underfoot the men who lay still and dead
in their blood. And through the dark night they heard the shrill cry of
a heron, and knew it for an omen sent by the gods, a promise to
them of victory.
In the Trojan camp was a council also held. And brave Hector
offered great rewards to the man who would go in the darkness to
where the Greek ships lay and find out how it fared with the men of
Agamemnon, and what plans were theirs.
And Dolon, the swift-runner and ill-favoured man, but one who
owned great riches of gold and bronze, stood up and said:
‘To the swift-sailing ships will I go as thy spy. But for reward must
I have the horses and bronze chariots of Achilles.’
‘No other man of the Trojans shall mount these horses,’ swore
Hector.
Then Dolon took his bow, on his shoulders cast a great wolf-skin,
on his head drew his helmet of ferret-skin, and with his sharp javelin
in his hand, went forth towards the seashore.
In the darkness Odysseus heard his stealthy footsteps.
‘Lo, here is some man, Diomedes,’ he said; ‘I know not whether
he be a spy or a plunderer of the dead. But let him pass, and then
will we rush on him and take him.’
Turning from the path, they lay down amongst the dead bodies
on the plain, still and silent as those they lay beside.
But when Dolon had gone a little way, they ran after him, and
Dolon, when he heard them, stopped, thinking they were
messengers from Hector, coming to bid him return. Less than a
spear’s-throw from him were they when he knew them for foemen
and fled before them.
But as two fierce hounds pursue a hare or a doe, so did
Odysseus and Diomedes hunt Dolon. They had wellnigh reached the
trench where the sentinels were placed when Diomedes called
aloud:
‘Halt! or my spear shall pin thee dead to the ground!’
Thereat he hurled his spear, but not with the wish to smite Dolon.
Over his right shoulder it flew, burying its sharp point in the ground in
front of him. Green with fear, and with chattering teeth, Dolon
stopped, and Odysseus and Diomedes panting, came up to him, and
laid hold of him.
‘Take me alive!’ said Dolon, weeping, ‘and a mighty ransom of
gold and bronze and iron shall be yours if ye but spare my life.’
‘Fear not,’ said Odysseus, ‘but tell us truly why thou comest thus
at dead of night into the camp of thine enemies.’
Then did Dolon, the coward, tremblingly tell his tale, and reveal to
Odysseus and Diomedes all that Hector had bidden him do. At their
bidding, too, he told them how all the Trojan forces lay, and how best
they could win into the camp.
‘At the farthest point from the men of Troy are encamped the
Thracians,’ he said. ‘Rhesus is their king, and fit for a god is his
golden armour and his chariot of gold and silver. His, too, are the
fairest horses mine eyes have seen, of great strength and height,
whiter than snow, and swift as the wind.’
Eagerly did Odysseus and Diomedes listen. But when he had
ended and begged them to take him a prisoner to the ships, or to let
him go free, grimly did Diomedes look at him.
‘Good is thy news, Dolon,’ he said, ‘yet nevermore shalt thou
have a chance of playing the spy, or of fighting against the men of
Greece.’
 With that he raised his mighty sword, and ere Dolon could beg for
mercy he smote him on the neck. Cleanly was his head shorn off,
and it rolled in the dust at the feet of Diomedes. His casque of ferret-
skin, and the grey wolf-skin, and javelin and bow did Odysseus and
Diomedes then take from him and held them aloft, an offering to
Athene. They placed them on a tamarisk bush, raising on it a mark of
long reeds and branches of tamarisk, lest they might miss the place
as they returned again ere dawn.
Across the plain did they hasten then, until they came to the
camp of the Thracians. Deep was the sleep of the warriors who lay,
each with his arms beside him, and his two horses standing near at
hand. And in the midst of them lay Rhesus the king, his great white
horses tethered to his chariot of silver and gold.
‘Lo, here is the man, and here are the horses of which Dolon
gave us tidings,’ said Odysseus.
And thereupon did the slaying begin.
Like a lion that rends a flock of sheep without a shepherd, even
so did Diomedes slay the men of Thrace. On this side and on that he
slew, till the earth grew red with blood, and terrible was the groaning
of the dying men. Twelve men did he slay, and as he slew them,
Odysseus dragged them to the side that a way might be left clear for
the white horses of Rhesus. For he feared that panic might seize
them were they to step in the darkness upon the dead men.
The thirteenth man was King Rhesus himself. An evil dream
made him draw his breath hard and quick, but ere he could awake
from sleep the sword of Diomedes took his life away. Then did
Odysseus drive the horses out of the camp, smiting them with his
bow, for he had no whip, and driving them onwards.
To Diomedes he whistled, for a sign that he should cease from
slaying and follow him and their lordly spoil. Still did Diomedes linger,
pondering whether he should drag the chariot with him, or slay yet
more of the Thracians. And as he pondered, Athene came to him.
 ‘Return to the ships, Diomedes,’ she said, ‘lest another of the
gods arouse the Trojans, and in flight thou art driven before them.’
Even then, indeed, was Apollo arousing one of the kinsmen of
Rhesus, who with great lament saw the dead and dying men and
knew that the horses of the king had been stolen away.
But swiftly did Diomedes and Odysseus spring on the backs of
the white horses, and swift as the snowy foam on the crests of
storm-driven waves did they dash through the darkness back to the
ships.
When they came to the tamarisk bush, where they had left the
bloody spoils of Dolon, Diomedes leapt to the ground, seized them
and placed them in the hands of Odysseus, and again mounted,
and, lashing the horses, dashed furiously onward.
The clang of the hoofs of the galloping horses struck first upon
the ears of old Nestor, and quickly did he and other lords of the
Greeks go to meet Diomedes and Odysseus.
Then did the two heroes rein in their horses and lightly spring to
the ground, and with hand-clasping and glad words were they
welcomed by their comrades.
And when he had told the tale of the slaying of the men of Thrace
and the taking of the horses of Rhesus, Odysseus, laughing, drove
the white steeds through the trench and stabled them beside the
other horses of Diomedes.
Then did he and Diomedes plunge into the sea and wash the
sweat and dust from off their limbs in the cold waves. Glad were their
hearts when they sat down to sup and poured forth an offering of
honey-sweet wine to Athene; but in the camp of the Trojans were
there shame and lamenting for the deeds that had been wrought in
the third watch of the night.
 CHAPTER X
THE FIGHTING ON THE PLAIN

The night passed, and grey dawn saw a mighty fight begin.
Fiercely did the battle wax and wane, and valiant deeds were
done that day.
Mightily fought Agamemnon, but against him fought the gods,
and when the sun blazed forth at noon, he and many another Greek
warrior, grievously wounded, were forced to leave the field.
An arrow, from the bow of Paris, smote Machaon, skilled
physician of the Greeks, and fear seized them lest he who healed
their wounds might himself perish.
Into his chariot did old Nestor take Machaon, and right willingly
his horses galloped back to their stables by the shore.
By the stern of his ship stood Achilles, watching the battle from
afar, and his dear friend and comrade, Patroclus, he sent speeding
to the tent of Nestor for tidings of the battle and to ask the name of
the wounded warrior.
Scornfully spake Nestor:
‘What matters it to Achilles which of the sons of Greece lie
wounded? Many chiefs of the Greeks have shed their blood this day,
yet Achilles heedeth not. Hast thou forgotten, Patroclus, that day
when thy father didst speak to thee of thyself and of Achilles? “Of
nobler birth than thou is Achilles,” he said, “and in might much
greater. Yet he is younger than thou, so see that thou counsel him
gently and wisely when there is need, and he will obey thee.” Even
now, Patroclus, thou mightest persuade Achilles to go forth to battle.
But if he will not go, then let him lend thee his armour so that the
men of Troy may flee before thee, thinking that Achilles goeth forth to
war once more.’
So did Nestor rouse the heart of Patroclus, and swiftly Patroclus
returned to the ship of Achilles.
Fiercer and ever more fierce grew the battle as the hours went
by. Up to the walls that the Greeks had built did the Trojans press
their furious way. Up the battlements, spear in hand, they swarmed,
nor heeded the storm of stones that crashed down upon them from
above.
In front of the gates lay a stone so huge that two strong men
could not together have lifted it and placed it on a wagon. With one
hand did mighty Hector, legs wide apart, hurl it against the great
double gates. Before it, hinges burst, bars smashed, and the gates
crashed backwards. Then in leapt Hector, his eyes flashing fire.
None but the gods could have withstood him, and on his heels came
the men of Troy. Before them they swept the Greek host to their
ships.
But down by the sea fought Ajax, and round him the Greeks took
their stand. Mighty was the wall of living men that sought to die for
their honour and for their own dear land.
Yet, like a great rock that the fierce floods of winter tear from a
mountain-side, and that crashes through the forests and thunders
down the valleys, destroying as it goes, so did Hector press onward.
Behind him in heaps lay the slain, the moans of the dying mingled
with the din of battle, and the dark night of death blinded the eyes of
many a mighty chief.
‘Thinkest thou to spoil our ships!’ called Ajax to Hector. ‘To the
gods, and not to the men of Troy do we owe our evil plight. Yet ere
long will Troy fall before us, and thou thyself wilt pray to Zeus to
make thy steeds fleet as falcons as they bear thee in shameful plight
back to thy city, across the plain.’
To Ajax did Hector make answer:
 ‘Blundering boaster art thou! Woe cometh this day to the Greeks!
And thou, Ajax, if thou hast courage to meet my spear, shalt be food
for the birds and the dogs.’
In his tent the heart of Agamemnon sank within him, and those
beside him did he counsel that they should drag their ships down to
the sea and swiftly sail away.
‘There is no shame in fleeing from ruin,’ said he.
But Odysseus and Diomedes replied with angry scorn to the
coward words of their overlord.
‘Let us go down to the battle, wounded though we be,’ said
Diomedes.
So they set forth, and with them went Agamemnon, and through
the long day did that mortal fight go on. Now would the Trojans
triumph, and again to the men of Greece would come the victory.
At last, before a huge stone, hurled by Ajax, did Hector fall. Like a
mighty oak smitten by lightning he fell, and the Trojans bore him
away, the black blood gushing from his mouth.
Then pressed the men of Greece the more. Back from the ships
they drove the men of Troy.
But to Hector where he lay a-dying came Apollo, and into his
fainting body and heart he breathed fresh strength and courage.
With strength as the strength of ten Hector once again faced the
foe, and before him the Greeks fell back in dismay.
Patroclus in his tent, tending the wounds of a friend, marked how
the Greeks fell back, and he groaned aloud.
‘To Achilles must I hasten,’ he said. ‘Who knows but that the time
has come when I may arouse him to join in the battle.’
 CHAPTER XI
HOW PATROCLUS FOUGHT AND DIED

While round the dark ships of Greece the fierce fight raged, Achilles,
from afar, listened unmoved to the din of battle, and watched with
stony eyes the men of Greece as they fell and died on the reddened
ground.
To him came Patroclus.
‘Why dost thou weep, Patroclus?’ asked Achilles. ‘Like a fond
little maid art thou that runs by her mother’s side, plucking at her
gown, hindering her as she walks, and with tearful eyes looking up at
her until the mother lifts her in her arms. Like her, Patroclus, dost
thou softly weep.’
Then Patroclus, heavily groaning, made answer:
‘Among the ships lie the bravest and best of the men of Greece,
sore wounded or dead. Pitiless art thou, Achilles, pitiless and
unforgiving. Yet if thou dost still hold back from the battle, give me, I
pray thee, thine armour, and send me forth in thy stead. Perchance
the Trojans may take me for the mighty Achilles, and even now the
victory be ours.’
Then said Achilles, and heavy was his heart within him:
‘These Greeks took from me my well-won prize, Patroclus. Yet let
the past be past; no man may keep his anger for ever. I have said
that until the men of Troy come to burn my own ships I will hold me
back from the battle. But take you my armour; lead my men in the
fight, and drive from the ships the men of Troy. But to others leave it
to chase them across the plain.’
Even as Achilles spoke, the strength of mighty Ajax had come to
an end, and with furious rush did the Trojans board the ships. In their
hands they bore blazing torches, and up to the sky rushed the
fiercely roaring flames.
Then cried Achilles, smiting his thighs:
‘Haste thee, Patroclus! They burn the ships! Arm thyself speedily,
and I will call my men!’
Corslet and shield and helmet did Patroclus swiftly don, and
girded on the silver-studded sword and took two strong lances in his
hand.
In the chariot of Achilles he mounted, and Automedon, best and
bravest of charioteers, took the reins.
Swift as the wild west wind were Bayard and Piebald, the two
horses of Achilles, and in the side harness was Pedasus, a horse
only less swift than they.
Gladly did the men of Achilles meet his call to arms, for fierce as
wolves were they.
‘Many times hast thou blamed me,’ cried Achilles, ‘because in my
wrath I kept ye back from battle. Here for ye now is a mighty fight,
such as ye love.’
To battle they went, and while Patroclus led them forth, Achilles in
his tent offered up an offering to Zeus.
Like wasps that pour forth from their nests by the wayside to sting
the boys who have stoned them, so now did the Greeks swarm from
their ships.
Before the sword of Patroclus fell a mighty warrior, and when the
men of Troy saw the shining armour of Achilles in his own chariot
their hearts sank within them.
Out of the ships were they driven, the fire was quenched, and
back to the trench rolled the tide of battle. In the trench writhed many
a horse and many a man in dying agonies. But clear across it leaped
the horses of Achilles, and close to the walls of Troy did Patroclus
drive brave Hector before him.
 His chariot then he turned, and headed off the fleeing Trojans,
driving them down to the ships. Before the furious rush of his swift
steeds, other horses were borne off their feet, other chariots cast in
ruins on the ground, and men crushed to death under his wheels.
Chief after chief did Patroclus slay. A mighty destroyer was he that
day.
One only of the chiefs of Troy kept his courage before the
destroyer who wore the shining arms of Achilles.
‘Shame on ye!’ cried Sarpedon to his men, ‘whither do ye flee? I
myself will fight this man who deals death and destruction to the
Trojan host.’
From their chariots leaped Sarpedon and Patroclus.
With the first cast of his spear Patroclus missed Sarpedon, but
slew his charioteer. Then did Sarpedon cast, and his spear whizzed
past Patroclus, and smote the good horse Pedasus. With a dreadful
scream Pedasus fell, kicking and struggling, in the dust. This way
and that did the other two horses plunge and rear, until the yoke
creaked and the reins became entangled. But the charioteer leaped
down, with his sword slashed clear the traces from Pedasus, and the
horses righted themselves.
Once again did Sarpedon cast his spear, and the point flew over
the left shoulder of Patroclus. But Patroclus missed not. Through the
heart of Sarpedon sped the fiercely hurled spear, and like a slim tree
before the axe of the woodcutter he fell, his dying hands clutching at
the bloody dust.
Furious was the combat then over the body of Sarpedon. One
brave warrior after another did Patroclus lay dead.
And more terrible still was the fight because in the ranks of the
men of Troy there fought now, in all-devouring wrath, the god Apollo.
Nine men, good warriors all, did Patroclus slay; then, waxing
bolder, he tried to climb the very walls of Troy.
 Three times did Apollo thrust him back, and when, a fourth time,
he attacked, the god cried aloud to him in anger, warning him not to
dare so much.
Against Patroclus did Hector then drive his war-horses, but
Patroclus, leaping from his chariot, hurled at Hector a jagged stone.
In the eyes it smote the charioteer of Hector, and the slain man
dropped to the ground.
‘How nimble a man is this!’ jeered Patroclus. ‘How lightly he
diveth! Were this the sea, how good an oyster-seeker would this
fellow be!’
 The point of the spear flew over the left shoulder of Patroclus (page 107)

Then from his chariot leaped Hector and met Patroclus, and the
noise of the battle was as the noise of a mighty gale in the forest
when great trees fall crashing to the ground.
When the sun went down, victory was with the Greeks. Three
mighty charges did Patroclus make, and each time he slew nine
men. But when, a fourth time, he charged, Apollo met him. In thick
mist he met him, and Patroclus knew not that he fought with a god.
With a fierce downstroke from behind, Apollo smote his broad
shoulders, and from off his head the helmet of Achilles fell with a
clang, rattling under the hoofs of the horses. Before the smiting of
the god, Patroclus stood stricken, stupid and amazed. Shattered in
his hands was the spear of Achilles, and his mighty shield clanged
on the ground.
Ere he could know who was the smiter, a Trojan ally drove a
spear between his shoulders, and Patroclus, sore wounded, fell
back.
Marking his dismay, Hector pressed forward, and clean through
his body drove his bronze spear. With a crash Patroclus fell.
‘Thou that didst boast that thou wouldst sack my town, here shall
vultures devour thee!’ cried Hector.
And in a faint voice Patroclus made answer:
‘Not to thee do I owe my doom, great Hector. Twenty such as
thou would I have fought and conquered, but the gods have slain
me. Yet verily I tell thee that thou thyself hast not long to live. Even
now doth Death stand beside thee!’
As he spoke, the shadow of Death fell upon Patroclus. No more
in his ears roared the din of battle; still and silent for ever he lay.
 CHAPTER XII
THE ROUSING OF ACHILLES

Fierce had been the fight before Patroclus died. More fiercely yet it
raged when he lay dead.
From his body did Hector take the arms of Achilles, and the dead
Patroclus would the Trojans fain have dragged to their city, there to
bring shame to him and to all the Greek host.
But for him fought the Greeks, until the earth was wet with blood
and the very skies echoed the clang of battle.
To Achilles came Antilochos, a messenger fleet of foot.
‘Fallen is Patroclus!’ he cried, ‘and around his naked body do
they fight, for his armour is held by Hector.’
Then did Achilles moan aloud. On the ground he lay, and in his
hair he poured black ashes. And the sound of his terrible lament was
heard by his mother, Thetis, the goddess, as she sat in her palace
down under the depths of the green sea.
Up from under the waves swiftly came she to Achilles, and
tenderly did she listen while he poured forth to her the tale of the
death of his dear comrade.
Then said Thetis:
‘Not long, methinks, shall Hector glory in the armour that was
thine, for Death presseth hard upon him. Go not forth to battle, my
son, until I return, bearing with me new and fair armour for thee.’
But when Thetis had departed, to Achilles in his sorrow came Iris,
fair messenger of the gods.
 ‘Unto windy Ilios will the Trojans drag the body of Patroclus
unless thou comest now. Thou needst not fight, Achilles, only show
thyself to the men of Troy, for sore is the need of Patroclus thy
friend.’
Then, all unarmed, did Achilles go forth, and stood beside the
trench. With a mighty voice he shouted, and at the sound of his voice
terror fell upon the Trojans. Backward in flight they went, and from
among the dead did the Greeks draw the body of Patroclus, and hot
were the tears that Achilles shed for the friend whom he had sent
forth to battle.
 The making of the arms of Achilles (page 113)

All that night, in the house of the Immortals, resounded the clang
of hammer on anvil as Hephaistus, the lame god, fashioned new
arms for Achilles.
Bronze and silver and gold he threw in his fire, and golden
handmaidens helped their master to wield the great bellows and to
send on the crucibles blasts that made the ruddy flames dance.
No fairer shield was ever borne by man than that which
Hephaistus made for Achilles. For him also he wrought a corslet
brighter than a flame of fire, and a helmet with a golden crest.
And in the morning light did Thetis dart down from snowy
Olympus, bearing in her arms the splendid gift of a god.
Glad was Achilles as he put on the armour, and terrible was his
war-cry as he roused the Greek warriors. No man, however sore his
wounds, held back when the voice of Achilles called him to the fight
once again. Wounded was Agamemnon, overlord of the Greeks, but
forth also came he. And there, while the sun rose on many a warrior
who would fight no more, did Achilles and Agamemnon speak as
friends once again, their long strife ended.
Hungry for war, with Achilles as their leader, did the Greeks then
meet the Trojans on the plain. And as a fierce fire rages through the
forest, its flames driven by the wind, so did Achilles in his wrath drive
through the host of Troy.
Down to the Scamander he drove the fleeing Trojans, and the
water reddened with blood, as he smote and spared not.
Merciless was Achilles; pitilessly did he exult as one brave man
after another was sent by him to dye red the swift flood of the
Scamander.
At length, at his lack of mercy, did even the river grow wrathful.