We are the Association for Child and Adolescent Mental Health, or ACAMH, for short. And this is ACAMH Learn. Hello, I'm Julieta Galante, I'm Deputy Director of the Contemplative Study Centre at the University of Melbourne. And today, I would like to talk about the evidence on mindfulness training for students. I'm going to mention key studies and explain and, also, where the gaps are and what things are important to take into account in practise. Mindfulness training is pretty much everywhere in education settings nowadays. It's there at university level and higher education. For example, there's a study that shows that 79% of medical schools in the US, they have some form of mindfulness training. And it's also at lower levels of education. For example, here is some stats from Australia, with more than half of the school teachers estimated to be using mindfulness in their settings. In the UK, there's a similar situation with a very recent trial in the UK called MYRIAD, that we're going to talk a little bit more about later on. But basically, they tested mindfulness training in 85 schools in the UK in a representative sample of 85 schools in the UK, because they were very seriously thinking of rolling out mindfulness training to all the schools in the UK. So it's very important to understand whether these probably millions of students who are undergoing mindfulness training, at the moment, are really benefiting from it. And it's not just about benefits, it's also about whether there is any harm potentially going on also for some of the students. And also, it's a matter of opportunity costs. So this means when we are rolling out some training, such as mindfulness, in all schools at all levels, that is something that students are doing, and they are not doing something else because they are doing that. So that's an opportunity cost. Is this the best thing that we can offer to everyone? So I'll start by describing this study, the Mindful Student Study, which is one that I did in Cambridge when I was a postdoc there a few years ago. I'm going to present this study because it is an example of a large, pragmatic, randomised controlled trial. So really, a study that provides really good evidence because it's reliable. And that was conducted in Cambridge with 600 students. So it does give you an idea of what happens when you roll out mindfulness on a large scale in a university. This was, as I said, a randomised controlled trial with 600 students. And the intervention that was tested was a very standard mindfulness-based programme called mindfulness skills for students. This programme was adapted for university students, and it consisted of eight weekly sessions of around an hour and a half. It was led by a teacher experienced in teaching mindfulness. And it was group-based, so groups of students would get together with the teacher and learn in person. This mindfulness training was compared with just receiving the support as usual. So the students who did mindfulness would get the usual support, and the students who were not assigned to doing mindfulness would also get that supportive as usual. meaning, the counselling service and other services that were available to them in the university campus. Very importantly, enrollment was voluntary for these mindfulness trial. So all the students who chose to take part were interested in mindfulness. These are the results of the trial. So the main outcome you can see there, T2, which is the exam period. It is when students were revising for their exams. And we measured this CORE-OM, which is the psychological distress that the students were having at the time. Psychological distress is the negative side of stress that distress that can actually be a risk factor for mental health problems. So at baseline, you can see that both groups, the control group support as usual represented in blue and the intervention group represented in red, were having the same amounts of psychological distress, which is what we would expect given that we randomised the groups. So they were comparable because the students were randomly assigned to the control or to the intervention. Then the students in the intervention arm received mindfulness training. Not all of them attended all the sessions, but still were included here. Some of them actually attended very few sessions, but they were still counted as doing the intervention. This is T1 after doing the mindfulness course. You can already see that the intervention group has lower levels of psychological distress than the control group. And this becomes even larger, the difference, when you get to T2, which is when students were quite stressed naturally, revising for their exams. And one year later, you can see the difference is smaller, but it's still there. It was still statistically significant. You could, perhaps, think that the difference is small anyway, even during the exam period, because the lines are still quite close. Well, that shows you how different ways of showing the data can give you a different impression. I'm going to show you now a different graph, where you will see that the difference seems bigger. But in any case, this is the difference that we would see in any application of preventative intervention for mental health problems or mental health promotion. Because, usually, it's more difficult to make a big impact than with treatment interventions. So this is to be expected. It still means that it's a very effective intervention. You can see here a different way of showing it. So we divided the students in each of the groups between those that had psychological distress levels that were above a clinical cutoff point, so psychological distress levels that would require some clinical attention and then students who were not qualifying for that. And you can see that during the exam period, most of the students in the control group actually were having distress levels that were at clinical levels. And in the mindfulness group, only 37%, which is still a considerable number, but the reduction is quite noticeable there. So we are helping quite a few students to not be having distress level at clinical rates. These are the papers. Actually, some of the papers that came out of that study that you can read more about. We also conducted a systematic review and meta-analysis to find other trials looking into university students and mindfulness training. We included 51 randomised controlled trials. And we could see that in the meta-analysis, mindfulness-based interventions reduced psychological distress, including all of these trials, at least, lasting for three months after the end of the intervention, which is important because many times, interventions have an effect just after you finish it. But there's an expectancy level that you should feel better because you have just finished an intervention, while if you still see that effect, a few months later, that is a more clear indicator that there is an actual change in the baseline levels of distress of that person. In this systematic review, we compared the intervention with passive control groups and active control groups. And there were still some effects compared to active control groups. So these are trials where mindfulness was compared with other interventions for student well-being. The only problem was that the quality of the randomised controlled trials was generally low. So the confidence in these results is, I would say, terribly low, but it's low as far as trials go. So this evidence is still much better than any other study that is not a randomised controlled trial. But trials should get better before we understand very well what's going on here. Now, I would like to go a little bit beyond the university students and just see what happens with adults, in general, because university students are already adults. And these skills are said to be lifelong skills that anyone can learn. This is what the proponents of mindfulness training say, that these are lifelong skills that you should be practicing for the rest of your life, and that it will not matter when you learn it. And when you do it, it will bring benefits. So we did another systematic review. And this time, we included 130 studies that included students, but also other types of adults. And this is what we found when we compare mindfulness with passive control groups, taking into account all of these studies. And we see that it does have effects on anxiety, depression, distress, and well-being compared to passive control groups. You can see that the blue diamond and the confidence intervals, which are in blue are all on the left-hand side of that vertical line, which is the line of no effect. But the grey, which is the grey bar is the prediction intervals. Those are touching that line. That means that we are not completely sure that in every setting, mindfulness training will work. This is where we compare mindfulness training with active controls, but nonspecific. Meaning, other interventions that these students went-- sorry, not just students, in this case, any adults went through that they are not specifically targeted to improve your mental health. For example, reading group, reading novels, for example. And in this case, we still see that mindfulness improved anxiety, depression, psychological distress, and well-being. But the results were less statistically significant. And we see that the diamonds are much closer to the non-effect line. And when we compared mindfulness with active and specific control groups, these are control groups that do target mental health. There is no visible difference between mindfulness and other interventions. This is a paper, if you'd like to read more about it. All of that was mindfulness for students or adults who were keen to do it, were volunteering for those studies, and they wanted to train in mindfulness. Now, what happens if you embed mindfulness in the curriculum at different levels? Again, we're talking about school level and university level. Embedding mindfulness in the curriculum means that every student will receive these mindfulness training independently of whether they are interested or not. This was the view before 2022, that I think was very prevalent. Many people in the field would see these as a really important, essential skill, mindfulness, and that schools should incorporate in the curriculum. It shouldn't be an optional thing. Actually, some people were going as far as saying that it's the most important life skill that children can develop. There was, for example, this important review, at the moment, at the time, that was saying that mindfulness had positive effects on several outcomes, including executive functioning, attention, depression, anxiety, stress, and negative behaviour. But these are all with small effect sizes. Now, this review had many outcomes. And there was no control for what we say, false discovery, which is what can happen statistically when you test many outcomes just by the laws of statistics, some of the outcomes, if you test many, will become positive and statistically significant, even if that is not true. There were also studies like this one, studies that were small. Perhaps they were randomised. Some of them were not, but they were trials of some sort. And they were having very promising results. For example, here, the children who participated, they reported fewer depressive symptoms post-treatment. And then at follow-up, also lower stress and greater well-being. But, for example, this one is not randomised. And it's also not pre-registered. And the review-- sorry the study, when it's not pre-registered, it means that it's not clear what the primary outcome and what the outcomes, in general, were the ones that the researchers meant to measure or meant to consider the principal, the main ones. So that can change afterwards. They can change it. If some of the outcomes that were important in the first place, when they planned it were not significant, then they can report different outcomes that were significant. So we don't know how this was thought of when they planned the study, but then they reported this. And if you see the schools that participated in this trial were those that were already quite enthusiastic about mindfulness, so they were selected. And these were schools that already had school teachers that were trained in mindfulness training. And they were already seeing that that worked in that school or schools that expressed a clear interest in receiving this training. And the other thing to notice is that some of the outcomes, it seems like from these abstract, they are not mentioned, but may not have been significant at post-treatment. So at post-treatment, you see they mentioned depressive symptoms, but it's not mentioned whether they reduce their stress or their well-being at post-treatment. And conversely, also the depressive symptoms are not mentioned at follow up. So you can see, when you measure many outcomes, and some are significant and some are not at different time points, this can get a little bit confusing. And what researchers tend to do is to report the ones that are significant. But actually, perhaps it wasn't that clear that the effects were positive. What's interesting is that the researchers that conducted their review, and then the small trial that I showed before, they were conducting that, knowing that these are preliminary studies. And then when those were positive, they did something that is really important and really good, which is to say, well, now, we're going to test these intervention in a very rigorous way. So all those biases that I was mentioning before were controlled in this big study. This was the biggest meditation study ever actually. And they took care, for example, to publish a protocol. So they said exactly what they would do, as opposed to the trial that I showed you before. As I said, this was a really big trial. This was done in 85 schools, including over 8,000 students. The reason also why this trial was done is because, as I said before, the UK government was considering including mindfulness training in every school in the country. So it's really good that they did this trial before actually rolling out mindfulness training in this way. So what did the trial test? It tested mindfulness training, in most cases, added to social emotional learning versus social and emotional learning alone. The trial targeted teenagers from 18 to 14 years old. And the important thing here is that these 85 schools were diverse. So they were coming from different backgrounds in different regions of the country and with different levels of interest and of knowledge of mindfulness. So the students were different. The schools were different, the teachers, the principals. And they compared. They waited for a year to measure changes, because what I said before, it's better to wait to be more confident that the effects, actually, last and have an impact. So what happened with this trial that had this clear primary outcome and clear protocol? Well, this is the publication for the trial. So you can read more there. But to summarise, there was no evidence that mindfulness was more effective than usual social emotional learning in improving students' mental health or well-being. So all the evidence that I showed you before, the review and the small trial, which also was replicated in other small trials in other countries, and in the UK as well, they were not replicated in this big trial and well conducted. What transpired is that it did help some students, usually older teenagers, but it was unhelpful for others. For example, students who already were having mental health problems. The students themselves had mixed views of mindfulness. So for some, they were looking forward to the mindfulness session. But for many of them, actually, the mindfulness session was something they were not at all looking forward to. And they were actually sometimes upset. Because, as I said before, with the opportunity cost, the mindfulness session was replacing something that they liked more. And they were more engaged with. So what happens in the end with things like this is that they don't engage. So here, you can see over 80% did not do their required mindfulness practise homework, which is practicing mindfulness at home, either sitting down and meditating or doing activities in a mindful way. Now, those who did practise mindfulness reported better mental health and mindfulness skills, so it's very mixed. This is not the only trial that actually showed this. So there were other well-designed trials that tested mindfulness in the curriculum. For example, these Spanish trial, which is also a culture that is a little bit different, and it still showed a very similar picture that the mindfulness and compassion programme that they tested was not able to improve students' mental health compared to the control group. And the trial below, this was conducted in Brazil. And it was with medical students. So this is at university level. And they saw the same effects. So now, you could see that mindfulness has different results, if it is embedded in the curriculum and compulsory for everyone, or if it is optional. If it is optional, if it is something that students can choose to do, it seems to be really good for the average person, for the average student, and for the average adult, actually. This doesn't mean that everyone benefits from mindfulness, and that is a blanket statement that everyone should do mindfulness. Even for people who voluntarily engaged in mindfulness practises, a large number report unpleasant experiences, which is not necessarily bad. But some of them, as you can see, 37% in one trial, report that these unpleasant and challenging experiences have a negative impact on functioning. Meaning, that their everyday life was affected. The way they function in their everyday life was affected by experiences that stemmed, they believe in their perception, from mindfulness training. And this was also reported among users of mindfulness apps, not just people who were doing mindfulness courses. This is, in general. This is not specific to students. And if you would like to know more, I recommend you watch this documentary available for free on YouTube. So going back to the engagement factor that I discussed briefly with the MYRIAD study. In a MYRIAD study, the big study in the UK, you can see that many students did not engage with mindfulness. They may have been required to actually sit down and close their eyes. But we don't know what was going on in their minds. And it's very likely that they were not engaging in the way that the teacher was thinking that the student was engaging. So engagement is key. And this is one of the reasons why it is so important that mindfulness is offered as part of a set of offerings for students. The other reason why it's important that mindfulness is an option, among other options, is because we're not sure, as we saw before, that mindfulness is better than other interventions for mental health promotion. This slide is, specifically, about engagement with mindfulness apps, because mindfulness apps seem to be now incredibly popular. And they are an easy alternative for institutions to offer to their students. I hear that many universities are offering subscriptions to popular mindfulness apps to their students. And they think that they are providing a really good service to their students by just offering this subscription, which is a really quick process for universities. But actually, a student of ours in the lab in Melbourne, she has been doing a survey. And she found that actually more than half of the users of mindfulness apps spend really little time with the mindfulness apps, very, very few minutes, 40 minutes or less per month. And most of them stop engaging. So what are the takeaways? We don't really have evidence that compulsory mindfulness training is good. And we actually have some evidence that it may be negative for some people. So we need to be really careful with that. When someone is not interested in mindfulness, we need to be careful to not insist that they should do it. But there is very good evidence actually, as far as mental health evidence goes, in this field, that is very difficult. mental health promotion-- Mental health is already a difficult field for generating good evidence. And mental health promotion is even harder. But there is good evidence within this context that offering mindfulness to university students as part of a package of well-being is good. But this evidence is focused on group-based mindfulness offered in person, led by a teacher. This evidence is not coming from trials testing mindfulness apps. So this is an important detail. So as I said, you need to offer other options because we don't know if mindfulness is really better than other interventions that are specific for mental health promotion or prevention. And the context matters. So what I was saying before about the apps, this is an example of context. The photo that you have below there is a group-based mindfulness-based programme. So there is a lot going on there that is not just learning mindfulness. And this is part of the effect of the course, that there is a safe space, that there is sharing of the experiences. And there is a teacher that is leading this facilitation. And the quality of delivery matters. So even within the delivery of the mindfulness courses, the training that the teachers receive, in this case, I'm talking about school teachers, specifically, matters as well. If the teachers themselves, the school teachers, are not convinced and are not well-trained to deliver mindfulness, the quality of that teaching and the engagement that it will generate will suffer. Thank you very much.