Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Diabetes Spectr. Author manuscript; available in PMC 2010 July 23.
Published in final edited form as:
Diabetes Spectr. 2009 September 21; 22(4): 226–230.
doi:  10.2337/diaspect.22.4.226
PMCID: PMC2909138

Mindfulness-Based Stress Reduction and Diabetes

Robin R. Whitebird, PhD, MSW, Mary Jo Kreitzer, PhD, RN, and Patrick J. O'Connor, MD, MPH

Overview of Mind-Body Approaches

Mind-body medicine is a field that focuses on “the interactions among the brain, mind, body, and behavior, and on the powerful ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health.”1 Mind-body approaches include guided imagery, biofeedback, clinical hypnosis, yoga, expressive arts therapies, and meditation. The potential of mind-body interventions to improve health and well-being of those with diabetes and related conditions has drawn significant interest, as researchers examine whether mindbody approaches constitute safe, practical, and cost-effective methods to assist those adapting to the demands of the diabetes, its care, and the associated stresses and elevated risk of depression.2 Mindfulness-Based Stress Reduction (MBSR) is a commonly used mind-body approach that has been demonstrated to positively affect people with various chronic illnesses. In this article, we will focus on applications of MBSR that may be relevant to those with diabetes.

Mindfulness-Based Stress Reduction

MBSR was developed in 1979 by Dr. Jon Kabat-Zinn and his colleagues at the Stress Reduction and Relaxation Program at the University of Massachusetts Medical Center.3 MBSR combines mindfulness meditation and gentle Hatha yoga into a structured clinical program that can be taught to individuals or in a group format. MBSR is a form of integrative therapy that taps into the powerful interaction of the mind and body.

Rooted in Theravada Buddhist vipassana (translated as “insight”)meditation,4 MBSR is a nonreligious program that focuses on cultivating an enhanced moment-to-moment nonjudgmental awareness of experience.5 Originally designed to help facilitate adaptation to the stressors of medical illness and assist people in managing stress and pain,3 MBSR has evolved into a practice that is being applied to a wide variety of health problems as well as being used for general health and overall stress reduction.

MBSR is offered in medical centers, clinics, and hospitals across the United States and abroad and consists of a 2.5-hour/week, 8-week course with a 1-day retreat.3,6 Participants receive training in formal mindfulness meditation techniques, including a body-scan meditation, a sitting meditation, and gentle Hatha yoga involving simple stretches and postures. The primary focus of the program is on the progressive development of mindful-awareness through the practice of mindfulness meditation.

The use of meditation as an intervention in mental health and health care has grown significantly during the past 30 years, expanding beyond a strictly religious and spiritual context. Meditation is broadly defined as the intentional self-regulation of attention, 7,8 with practices generally falling into two categories: those emphasizing concentration and those emphasizing mindfulness. An example of a concentrative practice is Transcendental Meditation, which includes the use of mantras (sounds or phrases used repetitively) to concentrate attention. Mindfulness practices, in contrast, focus on cultivating a nonjudgmental present moment awareness of the inner and outer world.

Both types of meditation are often associated with relaxation techniques; meditation, however, is fundamentally different in both its method and objective. Rather than seeking a state similar to deep relaxation in which bodily tension is released, the overall orientation of meditation is one of nonstriving and nondoing.6 The primary goal is on developing mental discipline leading to a state of deeper awareness and movement beyond reflexive thinking; a state of physiological relaxation is achieved, but it is not the primary focus of the practice.

In MBSR, mindfulness meditation assists practitioners in refining awareness through the practice of a nonreactive, nonevaluative, momentto-moment awareness from an intentionally nonjudgmental perspective. Participants are encouraged to observe their thoughts and emotions but to let them pass without judging them or becoming immersed in them.9 This allows both positive and negative thoughts and emotions to pass quickly and can cultivate a greater awareness of the ways thoughts, feelings, and behaviors affect emotional, mental, and physical health. This may also help reduce distractive or ruminative thoughts and assist practitioners in better noticing, understanding, and integrating their own perception of self and the environment.10 By combining mindfulness meditation with gentle yoga, MBSR also cultivates a greater awareness of the body and mind and the powerful interaction between them.

Body and Mind Dimensions of Diabetes

Before we address the applications of MBSR to those with diabetes, it is important to note that diabetes as a disease affects both body and mind.

Diabetes poses a major life stress that requires considerable physical, emotional, and psychological accommodation and coping. This heavy burden is related to at least four principal factors:

  1. Anxiety. In a study on behavior and mental health including > 200,000 adults, Li et al.11 found that people with diabetes were 20% more likely than those without diabetes to have an anxiety condition at some point in their lifetime. The highest rates of anxiety were reported in Hispanics and adults < 30 years of age.
  2. Depression. Depression is a common problem in people with diabetes. About 25% of adults with diabetes will experience depression at some point, although the similarly high prevalence of depression in those with other serious chronic diseases argues against a specific genetic link between depression and diabetes.2 Depression in people with diabetes is often long-lasting and severe, may be untreated more than half the time, and has high relapse rates.12 The American Diabetes Association recommends routine depression screening for people with diabetes, as well as long-term monitoring for depression recurrence in those with a history of depression.13
  3. Social burden. In addition to major issues related to anxiety and depression, diabetes has long been recognized for its potential to interfere with social interactions and relationships.14,15 The impact of social burden, sometimes referred to as stigmatization, is considerable, if incompletely understood.
  4. Diabetes complications Over the course of living with diabetes, > 70% of patients will suffer a heart attack or stroke, > 5% experience blindness in one or both eyes, ~ 10% experience amputation of a toe or worse, and ~ 5% must cope with end-stage renal disease. These and other major complications of diabetes add stress and further increase the risk of depression, anxiety, and poor quality of life.16,17

MBSR Research

Among the key questions to consider about MBSR and diabetes are 1) Can MBSR interventions help patients with diabetes cope with high rates of anxiety, depression, stress, and social burden?; 2) Can MBSR interventions lead to better control of blood glucose, blood pressure, or other metabolic parameters?; and 3) Can MBSR interventions lower the rates or risks of long-term macrovascular (heart attacks, strokes) or microvascular (eye, kidney, foot) complications in those with diabetes? To examine these questions, we first review what is known about the use of MBSR in diabetes and then briefly discuss the state of MBSR research in chronic disease and healthy populations to further explore the potential benefit MBSR may hold for diabetes care.

MBSR in diabetes

Adapting to the daily treatment needs and managing the psychosocial issues associated with diabetes can prove challenging and stressful for patients. It is widely recognized that stress is linked to a host of negative consequences for people living with diabetes, including impaired glycemic control, depression, decreased mental and physical health, and an overall decrease in quality of life.1832

There has been only one study to date looking at the effects of MBSR in patients with type 2 diabetes. A small, prospective, observational pilot study of 14 patients conducted by Rosenzweig et al.33 looked at the effects of MBSR on measures of A1C, blood pressure, body weight, and psychological symptoms, including anxiety, depression, somatization, and general psychological distress. This uncontrolled study found a reduction in A1C of 0.5% and reduced mean arterial pressure of 6 mmHg; decreases in depression, anxiety, and general psychological distress in patients completing the program were also observed. Analysis suggested that lifestyle changes did not account for the reduction in A1C. Mean body weight did not change for participants, and there were no reported changes in medication, diet, or exercise that could account for the improved glycemic control.

MBSR in other chronic conditions and in health

Although the research on MBSR and diabetes is sparse, there have been a number of studies on its use with other chronic conditions and in healthy populations. MBSR has been studied in chronic pain,4,34,35 cancer,3642 rheumatoid arthritis,43 fibromyalgia,4446 HIV,47 solid organ transplant,48,49 and severe psoriasis.6 It has been looked at in patients with depression and anxiety,5054 those receiving general medical care,55,56 in the general population for stress reduction,57 and to assist with behavioral lifestyle changes such as quitting smoking.58 It has also been studied in those providing care to others, such as caregivers of children with chronic conditions and mental health therapists.59,60 This research taken in aggregate has shown decreases in medical symptoms, improved functioning and quality of life, reductions in psychological distress, and decreases in mood disturbances such as depression and anxiety.

Recently MBSR has been combined with cognitive behavioral therapy into a new therapeutic modality called Mindfulness-Based Cognitive Therapy (MBCT). Teasdale et al.52 examined the impact of MBCT on a population of chronically depressed patients. The outcome measure, relapse/recurrence, was assessed during a 60-week period. Patients who had experienced three or more episodes of depression had a significantly reduced risk of relapse/recurrence with MBCT. Barnhofer et al.53 also recently looked at MBCT in addition to usual treatment compared to treatment alone for patients suffering from chronic-recurrent depression. They found a decrease in reported symptoms from the severe to mild level in the MBCT group and no significant change in the usual-treatment group.

Summary of MBSR effects

MBSR shows promise for facilitating adaptation to chronic illness and improving medical and psychological symptoms and quality of life. It is important to note, however, that although many studies observed benefits attributed to MBSR, study design or analysis limitations constrain the interpretation of results. In a critical review of MBSR research, Bishop61 noted that although there has been widespread and growing use of MBSR, many of the studies designed to evaluate its clinical effectiveness have been rife with methodological problems related to measurement and design. Many studies used repeated measures but lacked an active control group. Studies that have included control groups have generally had a passive control group, not controlling for time and attention provided during group support. Some studies have also used a combined intervention, thus making it difficult to draw conclusions on the effectiveness of MBSR per se. Although noting the serious limitations of the research in the field to date, Bishop nonetheless concluded that MBSR does appear promising and that serious continued investigation is warranted and needed.61

Potential Mechanisms Underlying MBSR

The primary hypothesized pathway through which MBSR likely affects health is through its effect on stress. There has been considerable discussion during the past decades of the role stress plays in overall health, with widespread belief that stress can lead to disease. Stress appears to influence the development of negative emotional states such as anxiety or depression, which in turn may negatively affect both behavior and biological processes. Behaviors such as smoking, overeating, lack of sleep, and exercise influence the risk of disease, and biological processes are affected by stress through the endocrine response system. This system is particularly reactive to stress and, through the hypothalamicpituitary- adrenocortical axis and the sympathetic-adrenal-medullary system, affects a wide range of physiological processes.62 Prolonged or repeated activation of the endocrine system can interfere with its ability to regulate physiological systems in the body, thus increasing the risk of physical and psychiatric disorders.63 Associations between psychological stress and disease have already been established for a number of conditions including depression, cardiovascular disease, and HIV/AIDS, with evidence emerging for many other conditions.62 Another mechanism that strongly affects the stress response is perception—how people perceive chronic illness and their adaptive coping skills. How people experience illness and whether they are able to adapt to a long-term chronic condition involves both their emotional and cognitive appraisal of their illness and their ability to accept and cope with the condition. Lazarus and Folkman64 identified appraisal as central to the stress process. MBSR, with its emphasis on experiencing life fully and nonjudgmentally, may assist in cultivating a more stable and nonreactive approach to life, even in stressful situations. The moment-to-moment focus of awareness often promotes a nonjudgmental acceptance of the present experience rather than ruminations on previous or anticipated events. This nonreactive acceptance of the present situation may help facilitate a more positive appraisal of illness, enhancing coping skills and decreasing stress.

Future Applications of MBSR in Diabetes Care

More work is needed to assess whether MBSR may enhance diabetes selfmanagement programs that mediate their effects through improved personal skills, self-efficacy, knowledge, and communication. Beyond these potential contributions, MBSR may also usefully address stress and psychosocial issues typically associated with chronic conditions such as diabetes. These stressors can interfere with adaptation to diabetes, which is clearly a key factor in long-term self-management and also affects metabolic outcomes through the neuroendocrine system.30,6569

In addition to MBSR, other techniques that focus on stress reduction such as patient empowerment, stress management, and biofeedback may help patients navigate psychosocial issues related to diabetes.68,70,71 These interventions have shown some success in improving the ability of patients to manage their diabetes,72 and, along with MBSR, may facilitate patient adaptation to the burdens of diabetes and the lifestyle changes diabetes care necessates.7375

Before the potential of MBSR as an adjunctive therapy for those with diabetes can be fully assessed, major questions need to be answered. Research in MBSR and diabetes is still in its infancy. Although some data suggest that MBSR may improve blood pressure and glucose control, much more work is needed to better understand the myriad possible applications of MBSR to diabetes care. For example, the positive impact of MBSR on pain and on depression or anxiety suggests a promising opportunity to evaluate the impact of MBSR on those with mental health conditions, painful neuropathies, or related complications. The ability of MBSR techniques to lower stress and improve coping could have very broad applications in the care of diabetes and related conditions.


At this time, there is insufficient evidence to assert that MBSR, a mind-body–based integrative therapy, is a proven intervention to help people adapt to the demands of diabetes and its treatment. There is, however, some evidence that MBSR can facilitate adaptation to other chronic conditions and may lead to an improved self-regulatory approach to the management of stress and emotions.61 MBSR interventions seek to establish and reinforce a nonreactive, nonjudgmental approach to thoughts and emotions and to cultivate acceptance through moment-to-moment awareness or “mindfulness.”76 This assists in managing stress by facilitating acceptance and modifying appraisal, a key component of the stress response. The long-term impact of MBSR on glucose and blood pressure control and on the risk of long-term diabetes complications remains to be determined but is a topic clearly worthy of increased research attention.


In Brief

Diabetes poses a major life stress that requires considerable physical, emotional, and psychological accommodation and coping. Mind-body therapies have drawn significant interest for their potential to assist in managing stress and adaptation to chronic illness. This review highlights the literature and research on Mindfulness-Based Stress Reduction to improve the health and well-being of individuals with diabetes.


1. National Center for Complementary and Alternative Medicine: NCCAM Backgrounder. Mind-body medicine: an overview. [Accessed 14 September 2009]. [article online].Available from
2. O’Connor PJ, Crain AL, Rush WA, Hanson AM, Fischer LR, Kluznik JC. Does diabetes double the risk of depression? Ann Fam Med. 2009;7:328–335. [PubMed]
3. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Dell Publishing; 1990.
4. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8:163–190. [PubMed]
5. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57:35–43. [PubMed]
6. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley TG, Hosmer D, Bernhard JD. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy(PUVA) Psychosom Med. 1998;60:625–632. [PubMed]
7. Caspi O, Burleson KO. Methodological challenges in meditation research. Adv Mind Body Med. 2005;21:4–11. [PubMed]
8. Goleman DG Jr, editor. Mind Body Medicine. Yonkers, N.Y.: Consumer Reports Books; 1993.
9. Praissman S. Mindfulness-based stress reduction: a literature review and clinician's guide. J Am Acad Nurse Pract. 2008;20:212–216. [PubMed]
10. Jain S, Shapiro SL, Swanick S, Roesch SC, Mills PJ, Bell, Schwartz GE. A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med. 2007;33:11–21. [PubMed]
11. Li C, Barker L, Ford ES, Zhang X, Strine TW, Mokdad AH. Diabetes and anxiety in US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabet Med. 2008;25:878–881. [PubMed]
12. Katon WJ. The comorbidity of diabetes mellitus and depression. Am J Med. 2008;21(11) Suppl.2:S8–S15. [PMC free article] [PubMed]
13. American Diabetes Association. All about diabetes. [Accessed 14 April 2009]. [article online]. Available from
14. Brod M, Kongso JH, Lessard S, Christensen TL. Psychological insulin resistance: patient beliefs and implications for diabetes management. Qual Life Res. 2009;18:23–32. [PubMed]
15. Tak-Ying Shiu A, Kwan JJ, Wong RY. Social stigma as a barrier to diabetes selfmanagement: implications for multi-level interventions. J Clin Nurs. 2003;12:149–150. [PubMed]
16. Oliveira AF, Valente JG, Leite Ida C, Schramm JM, Azevedo AS, Gadelha AM. Global burden of disease attributable to diabetes mellitus in Brazil. Cad Saude Publica. 2009;25:1234–1244. [PubMed]
17. Kautzky-Willer A, Handisurya A. Metabolic diseases and associated complications: sex and gender matter! Eur J Clin Invest. 2009;39:631–648. [PubMed]
18. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a metaanalysis. Diabetes Care. 2001;24:1069–1078. [PubMed]
19. Delamater AM, Kurtz SM, Bubb J, White NH, Santiago JV. Stress and coping in relation to metabolic control of adolescents with type 1 diabetes. J Dev Behav Pediatr. 1987;8:136–140. [PubMed]
20. Griffith LS, Field BJ, Lustman PJ. Life stress and social support in diabetes: association with glycemic control. Int J Psychiatry Med. 1990;20:365–372. [PubMed]
21. Jaber LA, Lewis NJ, Slaughter RL, Neale AV. The effect of stress on glycemic control in patients with type II diabetes during glyburide and glipizide therapy. J Clin Pharmacol. 1993;33:239–245. [PubMed]
22. Konen JC, Summerson JH, Dignan MB. Family function, stress, and locus of control: relationships to glycemia in adults with diabetes mellitus. Arch Fam Med. 1993;2:393–402. [PubMed]
23. Lloyd CE, Dyer PH, Lancashire RJ, Harris T, Daniels JE, Barnett AH. Association between stress and glycemic control in adults with type 1 (insulin-dependent) diabetes. Diabetes Care. 1999;22:1278–1283. [PubMed]
24. Niemcryk SJ, Speers MA, Travis LB, Gary HE. Psychosocial correlates of hemoglobin Alc in young adults with type I diabetes. J Psychosom Res. 1990;34:617–627. [PubMed]
25. Nomura M, Fujimoto K, Higashino A, Denzumi M, Miyagawa M, Miyajima H, Nada T, Kondo Y, Tada Y, Kawaquchi R, Morishita T, Saito K, Ito S, Nakaya Y. Stress and coping behavior in patients with diabetes mellitus. Acta Diabetol. 2000;37:61–64. [PubMed]
26. Peyrot M, McMurry JF., Jr Psychosocial factors in diabetes control: adjustment of insulin-treated adults. Psychosom Med. 1985;47:542–557. [PubMed]
27. Peyrot M, McMurry JF, Jr, Kruger DF. A biopsychosocial model of glycemic control in diabetes: stress, coping and regimen adherence. J Health Soc Behav. 1999;40:141–158. [PubMed]
28. Surwit RS, Schneider MS. Role of stress in the etiology and treatment of diabetes mellitus. Psychosom Med. 1993;55:380–393. [PubMed]
29. Surwit RS, Schneider MS, Feinglos MN. Stress and diabetes mellitus. Diabetes Care. 1992;15:1413–1422. [PubMed]
30. Tillotson LM, Smith MS. Locus of control, social support, and adherence to the diabetes regimen. Diabetes Educ. 1996;22:133–139. [PubMed]
31. van der Does FE, De Neeling JN, Snoek FJ, Kostense PH, Grootenhuis PA, Bouter LM, Heine RJ. Symptoms and well-being in relation to glycemic control in type II diabetes. Diabetes Care. 1996;19:204–210. [PubMed]
32. Weijman I, Ros WJ, Rutten GE, Schaufeli WB, Schabracq MJ, Winnubst JA. The role of work-related and personal factors in diabetes self-management. Patient Educ Couns. 2005;59:87–96. [PubMed]
33. Rosenzweig S, Reibel DK, Greeson JM, Edman JS, Jasser SA, McMerty KD, Goldstein BJ. Mindfulness-based stress reduction is associated with improved glycemic control in type 2 diabetes mellitus: a pilot study. Altern Ther Health Med. 2007;13:36–38. [PubMed]
34. Kabat-Zinn J, Lipworth L, Burney R, Sellers W. Four year follow-up of a meditation program for the regulation of chronic pain. Clin J Pain. 1986;2:159–173.
35. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33–47. [PubMed]
36. Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Support Care Cancer. 2001;9:112–123. [PubMed]
37. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction inrelation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology. 2004;29:448–474. [PubMed]
38. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med. 2003;65:571–581. [PubMed]
39. Carlson LE, Speca M, Faris P, Patel KD. One year pre-post intervention follow-up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based stress reduction (MBSR) in breast and prostate cancer outpatients. Brain Behav Immun. 2007;21:1038–1049. [PubMed]
40. Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR)on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med. 2005;12:278–285. [PubMed]
41. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med. 2000;62:613–622. [PubMed]
42. Lengacher CA, Johnson-Mallard V, Post-White J, Moscoso MS, Jacobsen PB, Klein TW, Widen RH, Fitzgerald SG, Shelton MM, Barta M, Goodman M, Cox CE, Kip KE. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology. 2009 February 20; Electronically published ahead of print. DOI: 10.1002/pon.1529. [PubMed]
43. Pradhan EK, Baumgarten M, Langenberg P, Handwerger B, Gilpin AK, Magyari T, Berman BM. Effect of Mindfulness-Based Stress Reduction in rheumatoid arthritis patients. Arthritis Rheum. 2007;57:1134–1142. [PubMed]
44. Grossman P, Tiefenthaler-Gilmer U, Raysz A, Kesper U. Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up benefits in well-being. Psychother Psychosom. 2007;76:226–233. [PubMed]
45. Sephton SE, Salmon P, Weissbecker I, Ulmer C, Gloyd A, Hoover K, Studts JL. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: results of a randomized clinical trial. Arthritis Rheum. 2007;57:77–85. [PubMed]
46. Lush E, Salmon P, Floyd A, Studts JL, Weissbecker I, Sephton SE. Mindfulness meditation for symptom reduction in fibromyalgia: psychophysiological correlates. J Clin Psychol Med Settings. 2009;16:200–207. [PubMed]
47. Creswell JD, Myers HF, Cole SW, Irwin MR. Mindfulness meditation training effect son CD4+ T lymphocytes in HIV-1 infected adults: a small randomized controlled trial. Brain Behav Immun. 2009;23:184–188. [PMC free article] [PubMed]
48. Gross CR, Kreitzer MJ, Russas V, Treesak C, Frazier PA, Hertz MI. Mindfulness meditation to reduce symptoms after organ transplant: a pilot study. Altern Ther Health Med. 2004;10:58–66. [PubMed]
49. Kreitzer MJ, Gross CR, Ye X, Russas V, Treesak C. Longitudinal impact of mindfulness meditation on illness burdenin solid-organ transplant recipients. Prog Transplant. 2005;15:166–172. [PubMed]
50. Kabat-Zinn J, Massion AO, Kristeller J, Peterson LG, Fletcher KE, Pbert L, Lenderking WR, Santorelli SF. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry. 1992;149:936–943. [PubMed]
51. Kutz I, Leserman J, Dorrington C, Morrison CH, Borysenko JZ, Benson H. Meditation as an adjunct to psychotherapy: an outcome study. Psychother Psychosom. 1985;43:209–218. [PubMed]
52. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000;68:615–623. [PubMed]
53. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM. Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther. 2009;47:366–373. [PMC free article] [PubMed]
54. Evans S, Ferrando S, Findler M, Stowell C, Smart C, Haglin D. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord. 2008;22:716–721. [PubMed]
55. Roth B, Robbins D. Mindfulness-based stress reduction and health-related quality of life: findings from a bilingual innercity patient population. Psychosom Med. 2004;66:113–123. [PubMed]
56. Roth B, Stanley TW. Mindfulness-based stress reduction and healthcare utilization in the inner city: preliminary findings. Altern Ther Health Med. 2002;8:60–62. 64–66. [PubMed]
57. Williams KA, Kolar MM, Reger BE, Pearson JC. Evaluation of a wellness-based mindfulness stress reduction intervention:a controlled trial. Am J Health Promot. 2001;15:422–432. [PubMed]
58. Davis JM, Fleming MF, Bonus KA, Baker TB. A pilot study on mindfulness based stress reduction for smokers. BMC Complement Altern Med. Electronically published ahead of print; DOI: 10.1186/1472-6882-7-2. [PMC free article] [PubMed]
59. Minor HG, Carlson LE, Mackenzie MJ, Zernicke K, Jones L. Evaluation of a mindfulness-based stress reduction (MBSR)program for caregivers of children with chronic conditions. Soc Work Health Care. 2006;43:91–109. [PubMed]
60. Shapiro SL, Brown KW, Biegel GM. Teaching self-care to caregivers: effects of mindfulness-based stress reduction on the mental health of therapists in training. Training Educ Prof Psychol. 2007;1:105–115.
61. Bishop SR. What do we really know about mindfulness-based stress reduction? Psychosom Med. 2002;64:71–83. [PubMed]
62. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298:1685–1687. [PubMed]
63. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171–179. [PubMed]
64. Lazarus R, Folkman S. Stress, Appraisal, and Coping. New York: Springer; 1984.
65. Dahl J, Wilson KG, Nilsson A. Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: a preliminary randomized trial. Behav Ther. 2004;35:785–801.
66. Davis WK, Hess GE, Harrison RV, Hiss RG. Psychosocial adjustment to and control of diabetes mellitus: differences by disease type and treatment. Health Psychol. 1987;6:1–14. [PubMed]
67. O’Connor PJ, Crabtree BF, Yanoshik MK. Differences between diabetic patients who do and do not respond to a diabetes care intervention: a qualitative analysis. Fam Med. 1997;29:424–428. [PubMed]
68. Surwit RS, van Tilburg MA, Zucker N, McCaskill CC, Parekh P, Feingolos MN, Edwards CL, Williams P, Lane JD. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care. 2002;25:30–34. [PubMed]
69. Fricchione GL, Stefano GB. The stress response and autoimmunoregulation. Adv Neuroimmunol. 1994;4:13–27. [PubMed]
70. Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment: results of a randomized controlled trial. Diabetes Care. 1995;18:943–949. [PubMed]
71. McGinnis RA, McGrady A, Cox SA, Grower-Dowling KA. Biofeedback-assisted relaxation in type 2 diabetes. Diabetes Care. 2005;28:2145–2149. [PubMed]
72. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, Rhodes S, Shekelle P. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143:427–438. [PubMed]
73. Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL. Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. J Consult Clin Psychol. 2007;75:336–343. [PubMed]
74. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25. [PubMed]
75. Richardson A, Adner N, Nordstrom G. Persons with insulin-dependent diabetes mellitus: acceptance and coping ability. J Adv Nurs. 2001;33:758–763. [PubMed]
76. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21:581–599. [PubMed]