Wong and colleagues are to be congratulated for the large scale randomised controlled trial on mindfulness-based cognitive therapy versus group psychoeducation for people with generalised anxiety disorder. ^{Reference Wong, Yip, Mak, Mercer, Cheung and Ling1} We have studied mindfulness awareness practice (MAP) amongst elderly individuals in an open-label study ^{Reference Rawtaer, Mahendran, Yu, Fam, Feng and Kua2} and more recently in a randomised controlled trial (ClinicalTrials.gov registration NCT02286791) and would like to share our experiences. Both studies involved community-living elderly people, with the second study involving individuals with mild cognitive impairment.

Wong et al highlight the use of self-reported questionnaires as one of the limitations of the study. We do agree and suggest that measurement of ‘psychobiomarkers’ may be the solution. Self-reports are useful for estimating psychological efficacy with task-based or behavioural approaches. ^{Reference Kemeny, Foltz, Cavanagh, Cullen, Giese-Davis and Jennings3} But many of the mental changes achieved even in short-term meditative practice are better measured through the physiological changes associated with achieving mental balance (conative, attentional, cognitive and affective) ^{Reference Wallace and Shapiro4} in contemplative practices. These are at the structural, cellular and biochemical level, and in preliminary findings in our study, changes in functional brain activity, neuropsychological tests, telomere lengths and oxidative stress markers were noted after 12 weeks of mindfulness practice (manuscript in preparation).

Like Wong and his colleagues, we too noted similar improvements in the control group which was provided weekly health education talks. We hold similar views that these resulted from the benefits of the group activity and the time and attention provided. Despite improvements in the control group, the changes were more significant in the MAP intervention arm.

Until we have identified the best biological measurement tools to identify the changes brought about by meditative practices, it may be too soon to dismiss mindfulness-based interventions for our patients. We agree that specific groups of patients with targeted needs would be better suited for mindfulness-based clinical programmes, and the challenge would be in identifying these patients and conditions. Would the authors comment on the implications of cultural factors and religious and spiritual beliefs in the usefulness of mindfulness interventions?