Patients with PH experience high psychological distress,¹ symptom burden,^2,3 and low quality of life,⁴ which is exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Current evidence suggests that psychological distress, such as depression and anxiety, are underrecognized and underdiagnosed, which means that symptoms are often untreated or under-treated by healthcare professionals.⁵ Inadequate management of anxiety or depression can have unfavorable influences on PH self-management and needed social support system. Despite advances in PH management, patients continue to struggle in symptom self-management, and this can have untoward consequences on mental and physical health. An integrated review of psychosocial and behavioral interventions and assessments indicates that complementary health approaches such as gentle breathing and mindfulness can reduce stress in patients with PH and be integrated into PH care settings.⁶

Stress experience is characterized by heightened awareness of perceived threat (real or imagined), often accompanied by exaggerated sympathetic outflow and diminished parasympathetic connection. Mindfulness practice is the most well-known and well-accepted modality of complementary health approaches among adults with cancer^7,8 and is beginning to gain traction in the PH community.⁹ One can learn simple mindfulness practice and incorporate it into daily living activities to enhance the relaxation response. The relaxation response experience is the critical defining characteristic of parasympathetic outflow that can facilitate the body's innate ability to counteract chemical and physiologic sequela of chronic stress. Our physical body is fully capable of harnessing the parasympathetic state, as demonstrated by reduced heart rate and respiratory rate. Qualitatively measured, patients with PH who received complementary health approach interventions described their deep relaxation experience as a sense of "time lost," "sleep like," and "body disconnectedness."¹⁰ Learning how to reach this state of relaxation using complementary health approaches can allow the stressed physical body to recover and recuperate.

Mindfulness practice can be an invaluable tool to temper our stress response. Mindfulness is the practice of training your body and mind to engage in full awareness by focusing attention, thoughts, and feelings in the present moment.¹¹ Studies have shown that mindfulness practice in PH (such as mindfulness-based stress reduction) had a positive impact in reducing anxiety among those who adhered to the method.⁹ Progressive muscle relaxation practice among patients with PH post-hospital discharge reduced depression and anxiety.¹² A multi-component integrative therapy program called Urban Zen Integrative Therapy was associated with reducing the severity of pain, anxiety, fatigue, and dyspnea symptoms in patients with PH.⁴ Mindfulness practice can be learned and practiced by anyone with the essential requirements of curiosity, interest, and the willingness to try. With a clear understanding of the basic concepts of mindfulness and regular mindfulness practice, one can gain comfort and confidence.

The practice of gratitude, either in thoughts or verbal expression, can shift our state of being from worry to calmness. Simply put, this practice is an extension of the mindfulness practice. In addition to bringing awareness to your current thoughts, feelings, and sensations, we focus more on the positive aspects of what we notice. Because our minds automatically default to a negative thinking mode, we have to make a conscious effort in this practice. Positive thinking will gradually become a routine, replacing habitual negative thinking with frequent and more extended practice sessions.

With daily practice, mindfulness can become a way of being that is incorporated into daily activities such as mindful breathing, mindful walking, mindful eating, and mindful listening. Being fully present (or aware) in everything you do requires practice, which means that one gains comfort and competence. First, recognize that our minds naturally wander. When yours does, you bring it back to the present moment by focusing on physical sensation at that moment, such as body-awareness meditation, which may be the easiest way to begin the practice. In this method, you pay attention to the physical body sensation and give each body part your full awareness and understanding (Figure 1).

Figure 1

Similarly, when practicing mindful breathing, you provide full attention to the details of breathing, such as the quality of the airflow, chest expansion, and abdominal rises and falls. Adopting mindfulness practice through regular practice can move our thinking into the present moment, which slowly lessens unhelpful or negative thoughts. Through the conscious awareness of the present moment, rather than what happened in the past and what may occur in the future, we become less preoccupied with things that we cannot change. This methodical conscious control of thinking in this state of being can lessen stress and anxiety.

Using a readily available mindfulness app can be an excellent introduction to the practice for a novice practitioner. Many mindfulness apps provide various practice modules according to the participant's level of prior exposure and available time. The key is the consistency of the approach. Through the practice of mindfulness, one can invoke a relaxation response that produces calmness and clarity. Additionally, a community of support through friends and colleagues is critical in promoting and encouraging the practice.