Dear Drs Schneider and Salerno:

Thank you for your commentary. And thank you for recognizing our efforts. We were very careful to be meticulous at all levels of the synthesis process.

You are correct to point out that several randomized controlled trials contradict our conclusion that the effects of transcendental meditation (TM) on blood pressure (BP) wane after 3 months.1 Because we believe that health behavior is not effective unless it is maintained, we collected data from the longest time point beyond the intervention for each study. Thus, we used the 12-month follow-up from Schneider et al2 in your first example and the 5.5-year findings from Schneider et al3 from your second example. That is, the long-term reductions in BP that were reported in these studies went into the summary effects of -3.3 mm Hg systolic and -1.8 mm Hg diastolic BPs. In addition, our moderator analyses, which also included Schneider and colleagues,2,3 showed impressive systolic BP reduction at <=3 months (-8.0), but beyond that, the effects waned (-0.69). As with any meta-analysis, the effects reflect the body of evidence, bringing together all findings, whether or not they are contradictory. Findings from Schneider et al2,3 provided only 2 studies of a total of 18.

Your third example, Schneider et al,4 was not included in our meta-analysis. Our search was conducted in March of 2021, and Schneider et al4 was accepted for publication in October of 2021. We are glad you brought this study to our attention. The average 20-month follow-up systolic BP findings of -3.3 mm Hg are consistent with the mean summary effect of -3.3 mm Hg that we found in our meta-analysis across all time points.

Your fourth example, Schneider et al,5 reflects a separate theme that runs through your commentary, that of clinical event outcomes. As you pointed out across your examples, Schneider and colleagues have shown that participants who engaged in TM showed reduction in the use of antihypertensive medications over 12 months compared with increases for the progressive muscle relaxation and health education groups.2 Compared with health education groups, they also showed a 48% reduction on the composite of total all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke over 5.4 years3 and a 48% relative risk reduction of hypertensive events over 20 months.4 Over a mean of 7.6 years, Schneider et al found a 30% risk reduction in cardiovascular mortality and a 23% reduction in all-cause mortality compared with controls.5 Although the long-term effects of TM interventions can have important clinical consequences, it is only those who continue their TM practice who will reap those benefits. Although we do not doubt the clinical consequences of reduced BP, we only focused on the effect of TM interventions on BP to address the limitations of previous meta-analyses. That is, we included a larger number of primary studies than previous meta-analyses. We computed moderator analyses to include quality indicators. And importantly, we included quasi-experimental designs that we believe more closely reflect real-life than randomized designs. Certainly, future meta-analysts might consider examining the effects of TM on clinical outcomes.

Again, we thank you for your thoughtful commentary. We enjoy the challenge of thinking beyond our work. We recognize the impressive contributions you and your team have made to this field, and we look forward to reading your future endeavors.

Acknowledgment

The authors thank Scott Easton for his review of an earlier version of this commentary.

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