レビュー論文：瞑想の実践と瞑想に基づく療法における有害事象：系統的レビュー(Adverse events in meditation practices and meditation-based therapies: a systematic review)

マルガリータ

出典：https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13225
https://doi.org/10.1111/acps.13225

Author：
M. Farias, E. Maraldi, K. C. Wallenkampf, G. Lucchetti
First published: 21 August 2020

© 2020 The Authors. Acta Psychiatrica Scandinavica published by John Wiley & Sons Ltd

CC BY-NC-ND 4.0
https://creativecommons.org/licenses/by-nc-nd/4.0/

Abstract

Objective

Meditation techniques are widely used as therapy and wellbeing practices, but there are growing concerns about its potential for harm. The aim of the present study is to systematically review meditation adverse events (MAEs), investigating its major clinical categories and its prevalence.

瞑想法はセラピーやウェルビーイングの実践として広く利用されているが、その有害性についての懸念が高まっている。本研究の目的は、瞑想の有害事象 (MAEs) を系統的にレビューし、その主要な臨床カテゴリーとその有病率を調査することである。

Method

We searched PubMed, PsycINFO, Scopus, Embase and AMED up to October 2019. Eligible studies included original reports of meditation practices (excluding related physical practices such as Yoga postures) with adult samples across experimental, observational and case studies. We identified a total of 6742 citations, 83 of which met the inclusion criteria for MAEs with a total of 6703 participants who undertook meditation practice.

2019年10月までにPubMed、PsycINFO、Scopus、Embase、AMEDを検索した。適格な研究には、実験研究、観察研究および症例研究全体にわたる成人サンプルを用いた瞑想実践 (ヨガの姿勢などの関連する身体的実践を除く) の最初の報告が含まれた。著者らは、合計6742件の引用文献を同定し、そのうちの83文献は、瞑想実践を行った合計6703人の参加者とともにMAEの包含基準を満たした。

Results

Of the 83 studies analysed, 55 (65%) included reports of at least one type of MAE. The total prevalence of adverse events was 8.3% (95% CI 0.05–0.12), though this varied considerably across types of studies – 3.7% (95% CI 0.02–0.05) for experimental and 33.2% (95% CI 0.25–0.41) for observational studies. The most common AEs were anxiety (33%, 18), depression (27%, 15) and cognitive anomalies (25%, 14); gastrointestinal problems and suicidal behaviours (both 11%, 6) were the least frequent.

分析された83件の研究のうち、55件 (65%) は少なくとも1種類のMAEの報告を含んでいた。有害事象の総有病率は8.3% (95% CI 0.05–0.12) であったが、これは研究の種類によって大きく異なり、実験研究では3.7% (95% CI 0.02–0.05)、観察研究では33.2% (95% CI 0.25–0.41) であった。最も一般的なAEは、不安(33%、18)、抑うつ状態(27%、15)および認知異常(25%、14)であった。胃腸障害および自殺行動(両方11%、6)の頻度が最も低かった。

Conclusion

We found that the occurrence of AEs during or after meditation practices is not uncommon, and may occur in individuals with no previous history of mental health problems. These results are relevant both for practitioners and clinicians, and contribute to a balanced perspective of meditation as a practice that may lead to both positive and negative outcomes.

瞑想の実践中または実践後のAE(有害事象)の発生は珍しくなく、精神衛生上の問題の既往歴のない個人でも起こり得ることを見出した。これらの結果は、実践者と臨床医の両方にとって関連性があり、ポジティブとネガティブの両方の結果につながる可能性のある実践としての瞑想のバランスのとれた視点に貢献する。

Summations

・Meditation practices are associated with the report of adverse events, particularly anxiety and depression.
・The overall prevalence of meditation adverse events (8.3%) is similar to those reported for psychotherapy practice in general.

・瞑想の実践は、有害事象、特に不安および抑うつの報告と関連している。
・瞑想による有害事象の全体的な有病率 (8.3%) は、一般的な心理療法の実施に関して報告されているものと同程度であった。

Considerations(検討事項)

・There is no standard assessment of adverse events in the reviewed literature, and randomized controlled trials are likely to under-report them.
・Future research should focus on how meditation outcomes are affected by context and individual differences, including appraisals of meditation experiences.

・レビューされた文献には有害事象の標準的な評価はなく、ランダム化比較試験はそれらを過小報告する可能性が高い。
・今後の研究では、瞑想の経験の評価を含め、瞑想の結果が状況や個人差によってどのように影響されるかに焦点を当てるべきである。

Introduction

Originally developed as a technique for spiritual contemplation, meditation is now widely used as a wellbeing and therapeutic practice. The 2012 US National Health Statistics reported that 8% of US adults (18 million) have used some type of meditation technique (1). While the major concern of the research literature has been to establish the physical and mental health benefits of meditation practices, there have been reports about its potential for harm stretching back to the 1970s (2, 3). In 1977, the American Psychiatric Association published a position statement on meditation where it strongly recommended that 'research be undertaken in the form of well-controlled studies to evaluate the possible specific usefulness, indication, contraindications, and dangers of meditative techniques'. Yet it has taken almost four decades of research before the literature acknowledged that there might be a bias towards exaggerating the clinical benefits of meditation practice and dismissing its potential adverse effects (4-6).

瞑想はもともと精神的な瞑想のための技法として開発されましたが、現在ではウェルビーイングや治療法として広く使われています。2012年のアメリカ国民健康統計によると、アメリカの成人の8%(1800万人)が何らかの瞑想法を使用したことがある (1)。研究文献の主な関心事は、瞑想実践の身体的および精神的健康上の利点を確立することであったが、1970年代(2, 3)にまで遡るその有害性の可能性についての報告がある。1977年、アメリカ精神医学会は瞑想に関する立場声明を発表し、「瞑想技術の具体的な有用性、適応、禁忌、危険性を評価するために、十分に管理された研究の形で研究を行うこと」を強く推奨した。しかし、瞑想実践の臨床的利点を誇張し、潜在的な副作用を無視するバイアスがあるかもしれないことを文献が認めるまでに、ほぼ40年の研究を要した (4-6)。

Although there is a wide range of meditation techniques originally developed across religious traditions, for the past 50 years the study of meditation has overwhelmingly focused on two techniques derived from Hindu and Buddhist traditions: transcendental meditation and mindfulness (7). More recently, there has been a growing interest in studying techniques associated with prosocial emotions and behaviours, such as loving-kindness and compassion meditation (8). Different types of meditation are likely to engage diverse cognitive mechanisms (9, 10) and have been found to be associated with contrasting neural correlates, an exception being the common recruitment of the insula across meditation types, a region involved in awareness of inner body states (11).

もともとは宗教的な伝統を越えて発達した幅広い瞑想技術があるにもかかわらず、過去50年間、瞑想の研究はヒンドゥー教と仏教の伝統から派生した２個の技術に圧倒的に焦点を当ててきた：超越瞑想とマインドフルネス (7)。最近では、親愛や慈悲の瞑想など、向社会的な感情や行動に関連する技術の研究への関心が高まっている (8)。異なるタイプの瞑想は、多様な認知メカニズムに関与する可能性が高く (9, 10)、対照的な神経相関と関連していることが発見されており、例外は瞑想のタイプを超えて島皮質の共通の動員であり、内部の身体状態の認識に関与する領域である (11)。

Meditation practices have been linked to the triggering of unusual or extraordinary states of mind, though not all positive (12, 13). Historical reports indicate that it has been used to depersonalize soldiers (14) and that some individuals can develop a ‘meditation sickness’ (15). The first handbook of meditation included contributions from leading cognitive psychotherapists (e.g. A Lazarus and A Ellis) about the occurrence of adverse events associated with these practices (16). Despite this early interest in meditation adverse events (MAEs), the prevailing reports of meditation for most of the last 20 years have largely ignored the possibility of these effects or even denied it (17). It is only more recently that clinicians and academic centres dedicated to the study of meditation-based interventions have begun acknowledging that some individuals may experience harmful or adverse effects after meditating (18). New studies of long-term meditators indicate that challenging, difficult or functionally impairing effects, which include hospitalization and suicidality, have a median duration of 1–3 years (19), and tentatively estimate, based on an average 5% rate of adverse events in the general psychotherapy literature, that in the USA alone almost 1 million of individuals may experience negative events associated with meditation (20).

瞑想の実践は、すべてが肯定的ではないが、通常とは異なる、または異常な精神状態の引き金と関連している(12, 13)。歴史的な報告によると、それは兵士の人格を奪うために使用されており (14)、一部の個人は「瞑想病」を発症する可能性がある (15)。瞑想の最初のハンドブックには、これらの実践に関連する有害事象の発生に関する著名な認知心理療法士(例：A LazarusやA Ellis)の寄稿が含まれていた (16)。瞑想の有害事象(MAE)に対するこの初期の関心にもかかわらず、過去20年間の瞑想に関する一般的な報告は、これらの効果の可能性をほとんど無視しているか、否定さえしている (17)。瞑想に基づく介入の研究に専念する臨床医や学術センターが、一部の個人が瞑想後に有害または有害な影響を経験する可能性があることを認め始めたのは、ごく最近のことである (18)。長期瞑想者を対象とした新たな研究では、入院や自殺傾向を含む治りにくい、困難、機能障害の影響の持続期間の中央値は1~3年であることが示されており (19)、一般的な心理療法の文献における有害事象の平均発生率5%に基づいて暫定的に推定すると、アメリカだけで約100万人が瞑想に関連した否定的な事象を経験する可能性がある (20) 。

There is an important distinction in the medical literature between serious adverse events (SAEs) and adverse events (AEs). In the European Union and the USA, SAEs are described within regulations for the testing of new medical products in clinical trials and specifically refer to occurrences that result in death, significant disability or incapacity, congenital anomaly or birth defect, are life-threatening, or require hospitalization (21, 22). The definition of other types of AEs is more broadly construed as any ‘undesirable’ or ‘untoward’ occurrences associated with, though not necessarily caused, by the use of a medical product. These regulations are relevant for the study of MAEs in two ways: meditation-based clinical trials across the EU and the USA are subjected to these regulations and must report all SAEs; on the other hand, they are not required to report other types of adverse occurrences that fall outside of this list, which is likely to lead to an under-reporting of MAEs – a general problem found with randomized controlled trials (23).

医学文献では、重篤な有害事象(SAE)と有害事象(AE)の間に重要な区別がある。欧州連合およびアメリカでは、SAEは臨床試験における新医薬品の試験に関する規則に記載されており、具体的には、死亡、重大な障害または機能不全、先天異常または出生欠損、生命を脅かすまたは入院を必要とする事象を指す (21, 22)。他の種類の有害事象の定義は、より広義には、医薬品の使用に関連して、必ずしも引き起こされるわけではないが、「望ましくない」又は「好ましくない」事象として解釈される。これらの規制は、２点でMAEsの研究に関連している：EUとアメリカの瞑想に基づく臨床試験は、これらの規制の対象となり、すべてのSAEを報告しなければならない。その一方で、このリストに含まれない他の種類の有害事象は報告する必要がないため、MAEの過少報告につながる可能性が高く、これはランダム化比較試験で見られる一般的な問題である (23)。

Within the psychotherapeutic literature, there is growing evidence that psychological treatments can be associated with AEs (13) with estimates ranging from 3% to 10% of patients who have become worse following psychotherapy (14). Similar findings have been reported for physical relaxation, which may in some individuals stimulate an increase in anxiety, an adverse event documented as ‘relaxation-induced anxiety’ (15). Rather than referring to these events as ‘undesirable’, which may be confused with something that is merely ‘unhelpful’, this literature has highlighted AEs as ‘harmful’, leaving no doubt that these are negative occurrences, often including symptom deterioration (24). In this review, we will adopt a similar characterization of MAEs as occurrences that are harmful or distressing, though of varying levels of severity.

心理療法の文献では、心理療法後に悪化した患者の3%から10%の範囲で推定されており (14)、心理療法が有害事象と関連し得るという証拠が増えている (13)。同様の所見が身体的弛緩についても報告されており、これは人によっては不安の増大を刺激する可能性があり、「弛緩誘発性不安」として報告されている有害事象である (15)。単に「役に立たない」ものと混同される可能性のあるこれらの事象を「望ましくない」と呼ぶのではなく、この文献では有害事象を「有害」と強調し、これらがしばしば症状悪化を含む否定的な事象であることに疑いの余地を残している (24)。このレビューでは、MAEの類似の特徴を、重症度のレベルは様々であるが、有害または苦痛の発生として採用する。

Despite a growing interest in this area, there has been no systematic review addressing potential AEs across the whole range of meditation reports. Two recent reviews have only included the literature on mindfulness-based interventions and found that these meditation interventions were no more likely to lead to harm than a wait-list control, or they identified an overall very low rate of adverse events (1% across 36 randomized controlled trials) (25, 26). By contrast, the present study aims to review the wide literature on MAEs by including all types of empirical reports, regardless of their methodological approach.

この分野への関心が高まっているにもかかわらず、瞑想報告の全範囲にわたって潜在的AEに対処する系統的レビューはない。最近の２件のレビューでは、マインドフルネスに基づく介入に関する文献のみが対象とされており、これらの瞑想介入が待機リスト対照と比べて害をもたらす可能性は高くないこと、または全体的に有害事象の発生率が非常に低いことが確認された(36件のランダム化比較試験で1%) (25, 26)。対照的に、本研究は、それらの方法論的アプローチにかかわらず、あらゆるタイプの経験的報告を含めることによりMAEsに関する幅広い文献をレビューすることを目的とした。

Aims of the study

The aim of this systematic review is to provide an assessment of the major categories of adverse events and its prevalence across the meditation literature.

この体系的レビューの目的は、瞑想に関する文献全体にわたって、有害事象の主なカテゴリーとその発生率を評価することです。

Methods

This systematic review followed the PRISMA guidelines, and it was registered on PROSPERO (2016:CRD42016040177). As this is the first systematic review of the literature involving meditation adverse events (MAEs), we utilized the ‘broad sweep’ approach recommended by the Cochrane Adverse Effects Methods Group (27) in order to gain a general view of the variety of adverse events, as well as attempting a preliminary estimate of their prevalence. This approach is recommended when specific adverse effects associated with a therapeutic intervention are not known and it is not possible to stipulate which ones will be the most relevant for the review.

この系統的レビューはPRISMAガイドラインに従い、PROSPERO (2016:CRD42016040177)に登録された。これは瞑想有害事象(MAEs)に関する文献の最初の系統的レビューであるため、有害事象の多様性の一般的見解を得るために、またそれらの有病率の予備的推定を試みるために、Cochrane Adverse Effects Methods Group (27) によって推奨された「broad sweep」アプローチを用いた。このアプローチは、治療介入に伴う特定の有害作用が不明であり、どの有害作用が審査に最も関連するかを規定することができない場合に推奨される。

Search strategies

We searched PUBMED, PSYCINFO, SCOPUS, EMBASE and AMED for articles published up to 31 October 2019. Our search strategy included the words ‘meditation’ or ‘mindfulness’ in combination with terms concerning somatic, psychological, and neurological or cognitive adverse events (see Table S1).

2019年10月31日までに発表された論文について、PUBMED, PSYCINFO, SCOPUS, EMBASEおよびAMEDを検索した。私たちの検索戦略には、身体的、心理的、神経学的または認知的有害事象に関する用語と組み合わせて「瞑想」または「マインドフルネス」という語が含まれていた (表S1参照) 。

Eligibility criteria(資格基準)

Our inclusion criteria consisted of studies employing a meditation technique or intervention with adult participants (aged 18 years of age or older) that reported original data on MAEs using any type of methodological approach – case studies, observational group studies (quantitative and qualitative) and experimental studies (quasi-experimental and randomized controlled trials) in any published language.

私たちの選択基準は、症例研究、観察グループ研究 (定量的および定性的) および実験研究 (準実験的およびランダム化比較試験) のいずれかの公表言語による方法論的アプローチを用いてMAEに関するオリジナルデータを報告した、成人参加者 (18歳以上) を対象とした瞑想法または介入を採用した研究から構成された。

Here, we consider MAEs the whole range of experiences associated with the practice of meditation, or meditation-based therapeutic interventions, which are harmful or distressing. We deemed eligible any study showing a harmful event or deterioration of current physical or mental condition that occurred during or after meditation practice. On the other hand, we wanted to focus specifically on meditation techniques, broadly defined as a mental practice where an individual brings the focus of attention to a particular object (whether a word, image, sound, breathing or feeling) or to the flow of conscious awareness. We thus excluded other so-called mind–body interventions, such as Qigong and Yoga involving the practice of physical exercise or asanas, for which there are separate literatures on their adverse effects (28, 29).

ここでは、有害または苦痛である瞑想の実践または瞑想に基づく治療的介入に関連する全範囲の経験をMAEと考える。瞑想の実践中または実践後に発生した有害事象または現在の身体的または精神的状態の悪化を示すすべての研究を適格とみなした。その一方で、私たちは特に瞑想技術に焦点を当てたいと思っていました、これは、個人が特定の対象(言葉でもイメージでも音でも呼吸でも感情でも)または意識の流れに注意を向ける精神的実践として広く定義されています。したがって、身体運動やアーサナの実践を伴う気功やヨガなど、有害作用に関する別の文献がある(28, 29)他のいわゆる心身介入は除外した。

Selection of studies

Two authors (KW, MF) independently reviewed the titles, abstracts, and screened the methods section of each study using the eligibility criteria. The full text of potentially eligible studies was read in full by 3 authors (MF, KW, EM). All disagreements were discussed until resolved.

著者2名(KW、MF)は、適格基準を用いて各研究のタイトル、要約を独立してレビューし、方法のセクションを選別した。適格と思われる研究の全文を著者3人(MF、KW、EM)が読んだ。意見の相違はすべて解決するまで議論された。

Data extraction

Data were extracted by one author (EM) and verified by a second author (MF). The data included reports about sample size, type of meditation practice, length of practice, major clinical categories of adverse events with a detailed breakup of symptoms, previous medical or psychiatric history, duration of adverse events and its prevalence. When MAEs were reported in general terms but the specific symptoms were missing, we contacted authors of studies to attempt obtaining missing data.

データは1人の著者 (EM) によって抽出され、2人目の著者 (MF) によって検証された。データには、サンプルサイズ、瞑想実践の種類、実践期間、症状の詳細な分類を伴う有害事象の主な臨床カテゴリー、既往歴または精神疾患歴、有害事象の持続期間およびその有病率に関する報告が含まれていた。MAEが一般的な用語で報告されているが、具体的な症状が欠けている場合、私たちは研究の著者らに連絡し、欠けているデータの入手を試みた。

Risk of bias(偏見のリスク)

Methodological quality was rated using the National Institutes of Health Quality Assessment Tools. We chose the tools that assessed case–control studies, observational cohort and cross-sectional studies; for the experimental studies and randomized clinical trials, we used the tools on controlled intervention studies and before–after (pre–post) studies with no control group. Two authors (MF and EM) read and graded the quality of studies. Grades where disagreement arose were discussed until a consensus was reached. The grading system considered outcomes of high, medium and low quality (see Table S2).

方法論的品質は国立衛生研究所品質評価ツールを用いて評価されました。症例対照研究、観察コホート研究および横断研究を評価するツールを選択した；実験研究および無作為化臨床試験では、対照介入研究および対照群を含まない前後 (pre-post) 研究のツールを使用した。著者2人 (MFおよびEM) が研究の質を評価した。意見の相違が生じた等級は、合意に達するまで議論された。この評価システムでは、質の高い、中程度、および質の低い結果が考慮された (表S2参照)。

Data analysis

A total of 6742 articles were found in the database search. Following the removal of duplicates, 5276 records were identified and screened (see Fig. 1). Of these, 5160 studies did not meet the inclusion criteria, which left a total of 116 articles for full text analysis. A total of 33 studies were excluded because they did not assess adverse events, or did not include original data (e.g. commentaries), totalling 83 studies for the final analysis (see Fig. 1). We considered that an MAE had occurred if a study reported at least one event. Two authors (MF and EM) reviewed the extracted data and categorized reported MAEs across broad (somatic, psychiatric and neurological or cognitive) and specific categories (such as pain, stress, fear or terror, cognitive anomalies, visual or auditory hallucinations). Some specific categories included a short range of terms that were employed across studies. For example, under ‘Visual or Auditory Hallucinations’ we considered the terms 'visual hallucinations’, 'auditory hallucinations’, ‘hearing voices’, and ‘unusual visualisations’; for the ‘Fear and Terror’ category we included the terms ‘fear’, ‘terror’, ‘panic attack’, and ‘agoraphobia’. Other categories were comprised of a wider range of terms which reflected the different methods employed, from self-report to biological instruments. For example, the ‘Stress’ category included the terms ‘stress’, ‘tension’, ‘restlessness’, ‘elevated cortisol levels’, and ‘increased blood pressure’; for the ‘Cognitive Anomalies’ category we included the terms ‘disorientation to time and place’, ‘confusion’, ‘attention problems’, ‘false memories’, ‘reduced memory accuracy’, and ‘perceptual hypersensitivity’.

データベース検索で合計6742の論文が見つかった。重複を除去した後、5276件の記録が同定され、スクリーニングされた(図1参照)。これらのうち、5160件の研究が組み入れ基準を満たしておらず、全文解析の対象となった論文は計116件であった。有害事象を評価していない、または元のデータが含まれていない(解説など)ため、合計33件の研究が除外され、最終解析では合計83件の研究が除外された(図1参照)。研究で少なくとも1件の事象が報告された場合、MAEが発生したと考慮した。著者2人 (MFおよびEM) は抽出されたデータをレビューし、報告されたMAEを広範なカテゴリー(身体的、精神的、神経学的または認知的)および特定のカテゴリー(痛み、ストレス、恐怖、認知異常、幻視、幻聴など)に分類した。いくつかの特定のカテゴリーには、研究全体で使用された短い範囲の用語が含まれていた。例えば、「幻視・幻聴」では、「幻視」、「幻聴」、「幻聴」、「異常な視覚」という用語を含めた；「恐怖と恐怖」のカテゴリーには、「恐れ」、「恐怖」、「パニック発作」、「広場恐怖症」という言葉を入れました。他のカテゴリーは、自己報告から生物学的器具まで、採用された様々な方法を反映したより広い範囲の用語で構成されていた。例えば、「ストレス」カテゴリーには、「ストレス」、「緊張」、「不穏」、「コルチゾール値の上昇」、「血圧の上昇」という用語が含まれていた。「認知異常」のカテゴリーには、「時間と場所に対する見当識障害」、「錯乱」、「注意力の問題」、「偽記憶」、「記憶精度の低下」、「知覚過敏」という用語を含めました。

Fig. 1
PRISMA diagram for selection of studies.

図 1
研究の選択のためのPRISMA図。

In addition, we calculated pooled prevalence estimates for studies with experimental and observational designs through Der Simonian and Laird’s random effects. Freeman–Tukey double arcsine transformation was used to stabilize variability in prevalence estimates. We excluded 10 studies that did not include the number of participants experiencing MAEs, and 1 study that only sampled individuals who had experienced MAEs. Given that case studies were equally not considered, a total of 57 reports were included in the prevalence estimates.

さらに、Der SimonianとLairdのランダム効果を用いて、実験的および観察的デザインの研究のプールされた有病率推定値を計算した。Freeman–Tukey二重アークサイン変換を用いて、有病率推定値のばらつきを安定化した。MAEを経験した参加者の数を含まない10件の研究、およびMAEを経験した個人のみをサンプリングした1件の研究を除外した。症例研究が同様に考慮されなかったことを考慮して、合計57件の報告が有病率推定値に含まれた。

Results

The 83 included articles (6464 meditation participants; exclusive of control condition participants) were published between 1974 and 2019. There were 54 experimental studies (n = 2673), 14 observational studies (n = 4023) and 15 case studies (n = 31). All except 3 of the observational studies (88, 90, 94) employed quantitative methods, and its two most recent reports consisted of large surveys that accounted for 58% of the total sample size. (12, 13) The studies employed a wide variety of meditation techniques (see Table 1), though the majority used either mindfulness or mindfulness-based interventions (MBIs) (61; 71%), or transcendental meditation (14; 16%).

対象とした83の論文(6464人の瞑想参加者；対照条件参加者を除く)は1974~2019年に発表された。54件の実験研究 (n=2673)、14件の観察研究 (n=4023) および15件の症例研究 (n=31) があった。観察研究のうち3件(88, 90, 94)を除くすべてが定量的方法を採用しており、最新の2件の報告は全サンプルサイズの58%を占める大規模調査で構成されていた (12, 13)。これらの研究は様々な瞑想法を採用していたが (表1参照)、大部分はマインドフルネスまたはマインドフルネスに基づく介入 (MBI) (61件；71%)、あるいは超越瞑想(14件；16%)を用いていた。

Table 1. Adverse events by type of study

コンテンツが結構長いので引用元論文を参照
htmlファイルは引用元の表を抜き出した物。

・AEs, adverse events; CBCT, cognitive-based compassion training; CGS, conditional goal setting ('the tendency to regard high-order goals such as happiness, as conditional upon the achievement of lower order goals', a characteristic usually observed among 'individuals with depression'; Crane et al., 2010, p. 204) ; GP, general population; GP-UnS, general population of university students; LKM, loving-kindness meditation; N/A, not applicable; NS, not specified; MBCT, mindfulness-based cognitive therapy; MBCT-SH, self-help mindfulness-based cognitive therapy; MBRP, mindfulness-based relapse preventions; MBSR, mindfulness-based stress reduction; NS, not specified; PBCT, person-based cognitive therapy; PCBMT, primary care brief mindfulness training; PTSD, post-traumatic stress disorder; TM, transcendental meditation.
・* Number of participants reporting at least one adverse event.
・† These adverse events were judged by either the authors or a trial steering committee as unreliable or unrelated to trial procedures.

・AEs、有害事象；CBCT、認知に基づく慈悲の訓練；CGS、条件付き目標設定(「うつ病患者」の間で通常観察される特徴である「幸福のような高次の目標を、下位の目標の達成を条件とみなす傾向」；Crane et al., 2010, p. 204)；GP、一般集団；GP-UnS、大学生の一般集団；LKM、慈愛の瞑想；N/A、該当なし；NS、指定なし；MBCT、マインドフルネス認知療法；MBCT-SH、自助マインドフルネス認知療法；MBRP、マインドフルネスに基づく再発予防；MBSR：マインドフルネスによるストレス軽減；NS、指定なし；PBCT、対人認知療法；PCBMT、プライマリーケアの簡単なマインドフルネス訓練；PTSD、心的外傷後ストレス障害；TM、超越瞑想。
・* 少なくとも1件以上の有害事象を報告した被験者の数。
・† これらの有害事象は、著者または試験運営委員会のいずれかにより、信頼性が低い、または試験手順と関連がないと判断された。

Fifty-five studies (65%) mentioned the occurrence of at least one type of MAE. A total of 1102 meditators experienced adverse events: 59 for experimental studies, 1012 for observational studies and 31 for case studies. All case studies described clinical cases of individuals who reported severe MAEs, such as psychosis, depersonalization and mania symptoms. Most randomized controlled trials did not state whether they included all types of AEs reported by participants or only SAEs.

55件の研究 (65%) が少なくとも１タイプのMAEの発生に言及していた。計1102人の瞑想者が有害事象を経験した。59人は実験研究、1012人は観察研究、31人は症例研究であった。全ての症例研究は、精神病、離人症および躁病症状のような重篤なMAEsを報告した個人の臨床症例を記述した。ほとんどのランダム化比較試験では、参加者から報告されたすべての種類のAEが含まれているのか、SAEのみが含まれているのかが記載されていなかった。

We used OpenMeta software to calculate the pooled prevalence estimates and levels of heterogeneity. The total pooled prevalence of MAEs for 57 reports, not including case studies, was 8.3% (95% CI 0.05–0.12), (see Fig. 2). The prevalence differed widely according to the methodological approach; for experimental studies, the pooled prevalence was 3.7% (95% CI 0.02–0.05), and for observational studies, it was 33.2% (95% CI 0.25–0.41) (see Figure S1 and S2). Statistical heterogeneity was considerable: I2 = 95% for all studies; I2 = 73% for experimental studies, and I2 = 95% for observational studies. This high level of heterogeneity is likely to reflect the methodologically diversity of studies and the lack of a standardized assessment of adverse events (Figs 3 and 4).

OpenMetaソフトウェアを用いて、プールされた有病率推定値と不均一性のレベルを計算した。症例研究を含まない57件の報告を統合したMAEの総有病率は8.3%(95% CI 0.05-0.12)であった (図2参照)。有病率は方法論的アプローチによって大きく異なった；実験的研究の統合有病率は3.7% (95% CI 0.02–0.05)、観察研究の有病率は33.2% (95% CI 0.25–0.41)であった(図S1およびS2参照)。統計的不均一性はかなり高かった：全試験でI2=95%であった；実験研究ではI2=73%、観察研究ではI2=95%。このような不均一性の高いレベルは、試験の方法論的多様性及び有害事象の標準化された評価の欠如を反映していると考えられる (図3及び図4)。

Fig. 2
Forest plots showing the pooled prevalence estimates of meditation adverse events for all studies.

図2
すべての研究の瞑想有害事象のプールされた有病率推定値を示す森林プロット。

[Correction added on 10 October 2020, after first online publication: an incorrect version of Figure 2 was published, and this has been corrected.]

[最初のオンライン公開後の2020年10月10日に追加された訂正：図2の誤ったバージョンが公開されたため、これを訂正した。]

Fig. 3
Proportion of broad types of meditation adverse events.

図3
瞑想による有害事象の幅広い種類の割合。

Fig. 4
Proportion of most common meditation adverse events.

図4
最も一般的な瞑想有害事象の割合。

Major categories of adverse events(有害事象の主な分類)

Psychiatric MAEs were described in 40 studies (49%). The most common symptoms were anxiety (18 studies) and depression (15 studies). Relatively common psychiatric adverse events included psychotic or delusional symptoms (10 studies), dissociation or depersonalization (9 studies), and fear or terror (9 studies). Trauma re-experience, in which participants relive or remember difficult, traumatic memories, was also moderately common (9 studies). Six studies (11%) reported suicidal ideation and behaviour, including three mentions of suicide attempts across different studies (2, 3, 19). The only study that sampled exclusively individuals who experienced MAEs reported that 10 (17%) of its participants had experienced suicidality.

精神科MAEは40件の研究 (49%)で報告された。最も一般的な症状は不安 (18件の研究)および抑うつ状態 (15件の研究)であった。比較的一般的な精神医学的有害事象は、精神病症状または妄想症状(10件の研究)、解離または離人症 (9件の研究)、および恐怖または恐怖 (9件の研究)であった。被験者が困難な心的外傷の記憶を再体験または記憶する心的外傷の再体験も中等度に多かった (研究9件)。6件の研究 (11%)が自殺念慮および自殺行動を報告しており、このうち3件は異なる研究で自殺未遂に言及していた(2, 3, 19)。MAEを経験した個人のみを抽出した唯一の研究では、参加者の10人 (17%)が自殺傾向を経験したことが報告された。

Somatic MAEs were reported across 26 studies (31%). The most common somatic AEs were stress or physical tension (11 studies), followed by pain (9 studies) and gastrointestinal problems (6 studies). Reports of localized pain varied from the abdomen or stomach (86, 90) to neck pain. (102) Most variables were assessed through self-report instruments, though some variables included a variety of psychophysiological and biological measures; for example, stress was measured via heart rate, blood pressure, skin conductance and cortisol measures, as well as self-report instruments.

体性MAEは26件の研究 (31%) で報告された。最も一般的な身体的AEはストレスまたは身体的緊張(11件の研究)であり、次いで疼痛(9件の研究)および胃腸障害(6件の研究)であった。局所的な疼痛の報告は、腹部または胃(86, 90)から首の痛みまで様々であった。(102) ほとんどの変数は自己報告書を用いて評価されたが、一部の変数には様々な心理生理学的及び生物学的指標が含まれていた。例えば、ストレスは、心拍数、血圧、皮膚電導度、コルチゾール測定、および自己報告測定器によって測定された。

Neurological or cognitive MAEs were reported across 17 studies (20%). The most common MAEs in this category were cognitive anomalous experiences reported in 14 studies, including thought disorganization (3, 89), amnesia (97), perceptual hypersensitivity (19) and impaired memory reliability (34, 40). We also found three studies that reported involuntary bodily movements and muscle contractions while meditating. (19, 94, 105).

神経学的または認知的MAEは研究17件(20%)で報告された。このカテゴリーで最も一般的なMAEは、14件の研究で報告された認知異常経験であり、思考の分裂(3, 89)、健忘 (97)、知覚過敏 (19)、記憶の信頼性低下(34, 40)などであった。また、瞑想中の不随意の身体運動と筋肉収縮を報告した3件の研究を見出した。(19, 94, 105)。

For 33 studies (64%), the AEs were experienced during or immediately after the practice or intervention. Longer-term effects of more than 6 months were reported by only 9 studies (17%), all of which were either observational or case studies. For the observational studies, data were based on retrospective self-reports.

33件の研究(64%)では、AEは診療中または介入直後に発生した。6ヵ月以上の長期効果が報告された研究は9件(17%)のみであり、いずれも観察研究または症例研究であった。観察研究では、データは回顧的な自己報告に基づいていた。

There were mixed reports in the observational studies concerning the association between length of meditation practice and frequency of AEs. Three of the earlier studies reported a positive association: one study found that participants who dropped out of meditation classes reported less AEs than those who kept meditating, and the most experienced meditators had higher symptoms of anxiety, confusion and depression (84). Another study found that participants with over 8 years of meditation experience reported the highest frequency of adverse effects, compared to those with <2 years’ experience (93). A survey of 221 meditators reported that length of meditation practice was positively associated with anomalous experiences, including auditory and visual hallucinations. (92) However, the largest survey failed to find any significant association (13).

瞑想練習の長さとAEの頻度との間の関連性に関する観察研究には様々な報告があった。初期の研究のうち３件は正の関連性を報告した：ある研究では、瞑想クラスを脱落した参加者は瞑想を続けた参加者よりもAEが少なく、最も経験豊富な瞑想者は不安、錯乱、抑うつの症状が高かった (84)。別の研究では、瞑想の経験が2年未満の参加者と比較して、8年以上の参加者が最も高い頻度で副作用を報告したことが明らかになった (93)。221人の瞑想者を対象とした調査では、瞑想の実践期間は幻聴や幻視などの異常体験と正の相関があることが報告された (92)。しかし、最大規模の調査では、有意な関連は認められなかった (13)。

Another variable that has been associated in the literature with AEs is meditation retreats (13, 19), where the practice is done more intensively. The data from the observational studies show that 42% (1689) of individuals had taken part in meditation retreats, with most of these (1409) being participants in the two largest surveys (12, 13). For case studies, retreat experience was not unusual though considerably lower (5;16%).

文献でAEと関連している別の変数は瞑想リトリート(13, 19)であり、そこではより集中的に実践が行われる。観察研究からのデータは、個人の42%(1689人)が瞑想リトリートに参加しており、これらの大部分(1409人)は２件の最大の調査(12, 13)の参加者であったことを示している。症例研究では、リトリートの経験はかなり低かったが、珍しいことではなかった (5；16%)。

※瞑想リトリート
日常生活の活動から離れ、瞑想実践者の実践をサポートするように設計された場所で専用の時間を過ごすこと。

One other result which cannot be ascertained from the majority of studies concerns whether participant factors, such as a past mental health history, are likely to make individuals more vulnerable to MAEs. Most randomized controlled trials are interventions designed to target individuals with particular mental health disorders, but overall these data do not allow us to ascertain whether individuals with a mental health history are more vulnerable than others to experiencing MAEs. The case studies, however, include such data for most participants (unavailable for 2; 9%). We found that most individuals (17; 55%) had no mental health history prior to the adverse events during or following meditation practice, compared with 11 (36%) participants.

大多数の研究からは確認できない別の結果は、過去のメンタルヘルスの病歴などの参加者の因子が、個人をMAEに対してより脆弱にする可能性があるかどうかに関するものである。ほとんどのランダム化比較試験は、特定の精神障害を有する個人を標的とするようにデザインされた介入であるが、これらのデータを総合すると、精神障害の既往を有する個人が他の個人よりもMAEを経験しやすいかどうかを確認することはできない。しかしながら、事例研究には、ほとんどの被験者(2の利用不可；9%)のこうしたデータが含まれている。ほとんどの被験者(17；55%)には、参加者11人(36%)と比較すると、瞑想練習中または瞑想練習後の有害事象の前にメンタルヘルスの既往歴がなかった。

Discussion

We have systematically reviewed 83 studies published from 1975 to 2019 containing an assessment of adverse events in association with meditation practice. Fifty-five of these studies, with a total of 1102 participants, reported at least one type of meditation adverse event (MAE), which we categorized into broad and specific categories. There is no previous systematic review of this literature, and our main aims were to address key questions concerning the prevalence of MAEs and the major categories of such adverse events. Additionally, we examined the time period of MAEs. Overall, we found that (i) the total pooled prevalence of MAEs was 8.3% (95% CI 0.05–0.12); for experimental studies, the prevalence was 3.7% (95% CI 0.02–0.05), and for observational studies, it was 33.2% (95% CI 0.25 to 0.41); (ii) AEs were varied and included somatic, psychiatric and neurological/cognitive reports; (iii) the most common symptoms reported were anxiety, depression, cognitive anomalies (e.g. thought disorganization), stress, and visual/auditory hallucinations; (iv) most AEs occurred during or immediately after the meditation practice or intervention, though this result must be read with caution given the very limited number of longitudinal studies and the use of retrospective self-report methods. Additionally, we found that (v) there were insufficient data from experimental and observational studies to examine participant factors associated with MAEs, though case studies reported that the majority of individuals did not have a history of mental health problems.

私たちは瞑想実践と関連した有害事象の評価を含む1975~2019年に発表された83の研究を系統的にレビューした。合計1102名の参加者を対象としたこれらの研究のうち55件で、少なくとも１タイプの瞑想有害事象 (MAE) が報告され、私たちはこれを広範なカテゴリーと特異的なカテゴリーに分類した。この文献の以前の系統的レビューはなく、私たちの主な目的はMAEの有病率とそのような有害事象の主要カテゴリーに関する重要な問題に取り組むことであった。加えて、MAEの期間を調べた。全体として、(i) MAEの全統合有病率は8.3% (95% CI 0.05–0.12) であることがわかった；実験的研究の有病率は3.7% (95% CI 0.02–0.05)、観察研究の有病率は33.2% (95% CI 0.25–0.41) であった；(ii) AEは多様であり、身体的、精神的、神経学的/認知的報告が含まれていた；(iii) 報告された最も一般的な症状は、不安、抑うつ、認知機能異常(例、思考の分裂)、ストレス及び幻視・幻聴であった；(iv) ほとんどのAEは瞑想の実践または介入の間または直後に発生したが、この結果は縦断的研究の数が非常に限られていることと遡及的自己報告法の使用を考慮して慎重に読まなければならない。加えて、私たちは、(v) MAEと関連した参加者の因子を検討するための実験的および観察的研究からのデータが不十分であることを見出したが、症例研究は、個人の大多数が精神衛生上の問題の病歴を持たないことを報告した。

The results on the prevalence of MAEs were inconsistent and require further scrutiny. There are reasons to suppose that the literature is under-reporting these adverse events. Our initial pool of almost 7000 citations resulted in only 83 original reports across 45 years of publications. A similar under-reporting has been found by two meta-analyses of mindfulness-based therapeutic interventions. Only 9 trials out of 47 (19%) (108) and 36 trials out of 231 (16%) (25) reported AEs. It is also likely that the majority of randomized controlled trials (RCTs) reporting MAEs only assessed serious adverse events (SAEs). For example, in a meta-analysis of mindfulness-based cognitive therapy for relapse prevention in recurrent depression over half of the studies only reported SAEs (109). In the RCTs included in the experimental studies of our review, the majority that found no MAEs failed to report whether they assessed only SAEs or also other AEs of less severity.

MAEの有病率に関する結果は一貫性がなく、さらなる精査が必要である。文献がこれらの有害事象を過少報告していると考える理由がある。最初に集めた約7000件の引用文献の結果、45年間の出版物の中で、83件のオリジナルの報告しかありませんでした。同様の過少報告が、マインドフルネスに基づく治療介入に関する２件のメタ解析で見出されている。47件中9件(19%)(108) と231件中36件(16%)(25) のみがAEを報告した。MAEを報告している無作為化比較試験 (RCT) の大部分は、重篤な有害事象 (SAE) のみを評価している可能性もある。例えば、再発性うつ病の再発予防のためのマインドフルネス認知療法のメタアナリシスでは、研究の半数以上がSAEのみを報告していた (109)。私たちのレビューの実験的研究に含まれたRCTでは、MAEを発見しなかった大多数が、SAEのみを評価したのか、重症度の低い他のAEも評価したのかを報告していなかった。

This under-reporting might be one of the causes of the discrepancy in the prevalence estimates between experimental and observational studies. Another possible reason is that individuals in the observational studies are practicing meditation within uncontrolled settings, in contrast with the structured context of MBIs which include psychoeducational sessions on how to manage distressing experiences arising during meditation or at other times (110). Note, however, that a small proportion of individuals in the observational studies (139; 3.5%) reported undergoing meditation-based therapy.

この過少報告は、実験研究と観察研究の間の有病率推定値の不一致の原因の１因である可能性がある。別の考えられる理由は、瞑想中やその他の時間に生じる苦痛な経験に対処する方法についての心理教育セッションを含むMBIの構造化された状況とは対照的に、観察研究の個人は管理されていない状況の中で瞑想を実践していることである (110)。しかしながら、観察研究では、瞑想に基づく治療を受けたと報告した人の割合が少なかった(139人；3.5%)ことに注意してください。

Observational studies might better reflect the present context of meditation practice, with many individuals practicing without face-to-face interaction, either using books or phone Apps. Although there are no estimates for the total universe of meditation App users, the number of downloads during 2019 for a single App, Headspace, was close to 40 million. (111) One other possibility for the higher prevalence of AEs in these studies was the relatively common frequency of retreat attendance (42% of the sample). It is unclear, however, whether this retreat experience falls under the category of a controlled, face-to-face setting, or an uncontrolled one. For example, the popular Vipassana 10-day retreats are undertaken in silence and with very minimal interaction with any teacher (112).

観察研究は、瞑想実践の現在の状況をよりよく反映している可能性があり、多くの個人が本またはスマートフォンアプリのいずれかを使用して、対面での対話なしで実践している。瞑想アプリユーザーの世界全体の推定値はないが、Headspaceという単一のアプリの2019年のダウンロード数は4000万近くだった (111)。これらの研究におけるAEのより高い有病率の別の可能性は、リトリート参加の比較的一般的な頻度(サンプルの42%)であった。しかし、このリトリート体験が、管理された対面環境に分類されるのか、管理されていない環境に分類されるのかは不明である。例えば、人気のあるヴィパッサナーの10日間のリトリートは、沈黙の中で行われ、教師との交流はごくわずかである (112)。

We found a variety of somatic, psychiatric and neurological/cognitive symptoms. The most frequently reported include those which meditation is expected to alleviate, such as anxiety, depression and stress. Various explanations have been put forward for the association between meditation and these symptoms, including by participants experiencing MAEs. These have suggested that adverse events are either initial barriers or difficulties that are ultimately beneficial for personal growth (3, 9, 88, 93, 105). Similar symptoms have been recorded in the traditional meditation literature. For example, one early compendium of Buddhist meditation techniques from the 5th century CE, the Dharmatrāta Meditation Scripture, reports that if the meditation is not carried out properly, the mind can become unstable, restless or confused, and the meditator feel dull, confused and sunken (113). Such adverse symptoms are not looked upon in a positive light, as may be the case with some modern meditators, but as consequences of practicing meditation incorrectly (114).

様々な身体症状、精神症状、神経/認知症状を認めた。最も頻繁に報告されているのは、不安、抑うつ、ストレスなど、瞑想によって軽減されると期待されているものです。瞑想とこれらの症状との関連については、MAEを経験した参加者によるものを含め、様々な説明がなされている。これらは、有害事象が個人の成長にとって最終的に有益である初期の障壁または困難のいずれかであることを示唆している(3, 9, 88, 93, 105)。同様の症状は伝統的な瞑想の文献に記録されている。例えば、西暦5世紀の仏教の瞑想法の初期の総集編であるダルマトラータ(Dharmatrāta)瞑想経典には、瞑想が適切に行われないと、心が不安定になり、落ち着きがなくなり、混乱し、瞑想者は鈍感になり、混乱し、沈んだ気分になると報告されている (113)。このような有害な症状は、一部の現代の瞑想者の場合のように肯定的には見られず、間違った瞑想の実践の結果として見られている (114)。

Other explanations put forth in the medical and psychological literature include the intensity of meditation practice (19, 115), the competence of the teacher and participant vulnerabilities, although the latter have sometimes been found to enhance the positive effects of meditation – such as for recurrently depressed individuals with higher rates of childhood trauma (48, 110). Concerning participant vulnerability, one factor that has been suggested to precipitate MAEs (110), the analysis of case studies indicated that the majority of individuals suffering from severe MAEs had no previous mental health record. This is an important finding which needs to be further explored in future studies.

医学および心理学の文献で述べられている他の説明には、瞑想の練習の強度(19,115)、教師の能力、参加者の脆弱性が含まれていますが、後者は瞑想のプラスの効果を高めることが時々発見されています -- より高い割合で幼少時のトラウマを持つ再発性うつ病の個人のように(48, 110)。MAEを誘発することが示唆されている要因の１因である参加者の脆弱性に関して (110)、症例研究の分析は、重度のMAEに苦しむ個人の大多数が以前にメンタルヘルスの記録を持っていないことを示した。これは今後の研究でさらに検討する必要がある重要な発見である。

The results of this systematic review give rise to various difficult questions. For example, how can adverse events be differentiated from distressing experiences which can be understood as integral to meditation practice? And what is the role of cultural–religious context and individual appraisal in framing meditation experiences either as harmful or constructive events? Lindahl et al. (116) have suggested that a person-centred approach is the most adequate way of understanding the variety of unusual experiences stimulated by meditation practices. This type of approach relies less on formal diagnosis and more on the practitioner’s agency and autonomy in deciding when meditation distressing experiences require additional support through social, psychological or medical interventions.

この系統的レビューの結果は様々な困難な疑問を生じさせる。例えば、有害事象は、瞑想の実践に不可欠であると理解できる苦痛を伴う経験と、どのように区別できるのだろうか？そして、瞑想体験を有害または建設的な出来事として骨組みの中で、文化的・宗教的文脈と個人の評価はどのような役割を果たすのだろうか？Lindahl et al. (116)は、瞑想の実践によって刺激されるさまざまな珍しい経験を理解するには、人間中心のアプローチが最も適切な方法であると示唆している。この種のアプローチは、正式な診断よりも、瞑想の苦痛体験が社会的、心理的、または医学的介入による追加的な支援を必要とする場合を決定する際の、実践者の主体性と自律性に依存している。

Before such questions can be properly addressed, we need to better understand how appraisals might play a moderating role in MAEs. This matter has been raised elsewhere. For example, the literature on schizotypal traits and psychosis suggests that experiences which are usually categorized as anomalous can be offered positive appraisals, in which case they will not become distressing and harmful (117, 118). To put this into the context of meditation, if we consider the experience of an altered sense of self, including the loss of body awareness or loss of individual self reported in some of the reviewed studies (93, 94), a religious framework may appraise this as a positive event, though for some it is likely to be appraised negatively, for example as a negative realization of aloneness or a loss of one’s fundamental sense of identity. Further research into how appraisals might moderate meditation adverse events is likely to bring important insights.

※このような疑問に適切に対処する前に、評価がMAEにおいてどのように緩和的な役割を果たすかをよりよく理解する必要がある。この問題は別のところで取り上げられている。例えば、統合失調症の特性と精神病に関する文献は、通常は異常と分類される経験を肯定的に評価することができることを示唆しており、その場合、それらは苦痛や有害なものにはならない(117, 118)。これを瞑想の文脈に当てはめると、いくつかのレビューされた研究(93, 94)で報告されている※身体認識の喪失や個人の自己の喪失を含む、自己の変化した感覚の経験を考慮すると、宗教的な枠組みはこれを肯定的な出来事として評価するかもしれないが、一部の人にとっては、例えば孤独の否定的な認識や自己の基本的なアイデンティティの感覚の喪失として、否定的に評価される可能性が高い。評価が瞑想の有害事象をどのように緩和するかについてのさらなる研究は、重要な洞察をもたらす可能性が高い。

※これは危険。自傷行為が正しいと間違って伝わる危険性がある。

This systematic review has a number of limitations. The absence of standardized measures in the literature, as well as the passive monitoring of AEs (or exclusively reporting SAEs), is likely to have led to an underestimation of the actual rate of AEs, particularly in experimental studies. On the other hand, the observational data preclude any clear causality assessment between meditation practice and AEs. In addition to the factors mentioned earlier, such as the high frequency of retreat experiences in this sample, it is also possible that participants predisposed to heightened levels of anxiety and depression are more likely to begin or maintain a meditation practice to manage their symptoms – in support of this hypothesis, a recent study of over 12,000 individuals who use the meditation App Calm has found that over 40% reported mental health diagnoses (119).

この系統的レビューには多くの限界がある。文献に標準化された測定値がないこと、およびAEの受動的モニタリング (またはSAEのみを報告すること) が、特に実験的研究において、AEの実際の発生率の過小評価につながった可能性が高い。一方、観察データは瞑想実践とAEの間の明確な因果関係評価を妨げている。このサンプルでのリトリート経験の高頻度など、先に述べた要因に加えて、不安や抑うつのレベルが高い傾向にある参加者は、症状を管理するために瞑想の練習を開始または維持する可能性が高いことも考えられます - この仮説を裏付けるように、瞑想アプリCalmを使用している12,000人以上の個人の最近の研究では、40%以上がメンタルヘルスの診断を報告していることがわかりました (119)。

There is a long away ahead before we can ascertain for whom, when and under what circumstances do particular types of negative meditation-related experiences arise, and what are their long-term effects. We urgently need to move from passive monitoring of AEs to an active standard assessment of meditation experiences which include negative effects. This could be achieved by using a combination of relevant validated scales (e.g. for positive and negative affect, and depersonalization), and, given the likely moderating role of appraisals, assessing the frequency and interpretation of unusual experiences may prove particularly important (120).

瞑想に関連した特定のタイプのネガティブな経験が、誰にとって、いつ、どのような状況で生じるのか、また、それらの長期的な影響は何かを確認するには、まだ長い時間がかかる。AEの受動的モニタリングから、負の効果を含む瞑想経験の能動的標準評価への移行が至急に必要である。これは、妥当性が確認された適切な尺度(例えば、肯定的な感情と否定的な感情、離人感)を組み合わせて使用することによって達成される可能性があり、評価が緩和的な役割を果たす可能性があることを考えると、異常な経験の頻度と解釈を評価することが特に重要であることが証明されるかもしれない (120)。

Significant advances in this area are also likely to result from changing the way results are reported. If studies were to provide the individual-level data, even if in a supplement or archive, instead of only reporting the group-level data, this would generate the datasets we are currently missing to analyse how individuals with different baseline characteristics, or undertaking meditation within different contexts, may be variably affected.

この分野での大きな進歩は、結果の報告方法の変更によってももたらされる可能性が高い。研究がグループレベルのデータだけを報告するのではなく、たとえ補足やアーカイブであっても、個人レベルのデータを提供することができれば、異なるベースライン特性を持つ個人、または異なる文脈の中で瞑想を行う個人がどのように様々な影響を受けるかを分析するために、現在欠けているデータセットを生成することができます。

How should clinicians address the results of this systematic review, which indicates that MAEs are not uncommon or rare, and articulate them with the benefits of meditation practice, as well as the popular interest in these practices? A first step is to inform individuals of the possibility of these AEs. Researchers and centres involved in the study of meditation have the ethical duty of informing all taking their courses about the existence and prevalence of MAEs, and clinical trials should include consent forms that acknowledge that these adverse events may occur.

MAEが珍しくもなく稀でもないことを示しているこの系統的レビューの結果に臨床医はどのように対処すべきか、またこれらの実践に対する一般的な関心と同様に、瞑想実践の利点とそれらを明確に説明すべきか？最初のステップは、これらの有害事象の可能性を個人に知らせることである。瞑想の研究に携わる研究者や施設は、MAEの存在や有病率について受講者全員に知らせる倫理的義務があり、臨床試験にはこれらの有害事象が起こる可能性を認める同意書を含めるべきである。

A greater awareness of this topic would not only help dealing more promptly with potential adverse events, but it would have an important additional benefit: dispel prejudice about those who suffer them. Raising awareness of potential AEs will disseminate a less hyped (6) and more objective understanding of meditation as a practice that may lead to both positive and negative experiences.

このテーマに対する認識を高めることは、潜在的な有害事象に迅速に対処するのに役立つだけでなく重要な追加的利益をもたらします：有害事象に苦しむ人々に対する偏見を払拭すること。潜在的な有害事象の認識を高めることは、肯定的な経験と否定的な経験の両方につながる可能性のある実践としての瞑想について、あまり誇張されておらず (6)、より客観的な理解を広めることになる。

In conclusion, this first systematic review of meditation adverse events covering almost 5 decades of studies has found a wide range of potential negative symptoms. The ethical obligation to do no harm urges clinicians and researchers to promote practices of active monitoring of MAEs. Given the popularity of meditation practices, further research into this area should become a priority.

結論として、約50年間の研究を網羅する瞑想有害事象のこの最初の系統的レビューは、広範囲の潜在的陰性症状を見出した。危害を加えないという倫理的義務は、臨床医および研究者にMAEの積極的モニタリングの実践を促進するよう促す。瞑想法の人気を考えると、この分野のさらなる研究が優先されるべきである。

Acknowledgements

EM was supported by São Paulo Research Foundation (FAPESP research grant 2016/00368-6), and GL received a Research Productivity Scholarship (Level 2 Medicine) from the Brazilian National Council for Scientific and Technological Development (CNPq).


Declaration of interest

MF receives royalties from one popular science book on meditation and one academic Handbook of meditation. The remaining authors have no conflict of interest to declare.


Supporting Information(補足情報)

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Figure S1 Forest Plots showing the pooled prevalence estimates of meditation adverse events for experimental studies.

Figure S2 Forest Plots showing the pooled prevalence estimates of meditation adverse events for observational studies

Table S1 Electronic Database Search Strategy

Table S2 Quality ratings based on the National Institutes of Health and quality assessment tool.

Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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