Mindfulness intervention for mild

cognitive impairment led to

attention-related improvements and
neuroplastic changes: Results from a
9-month randomized control trial
Junhong Yu
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 Journal of Psychiatric Research 135 (2021) 203–211

Contents lists available at ScienceDirect

Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Mindfulness intervention for mild cognitive impairment led to

attention-related improvements and neuroplastic changes: Results from a
9-month randomized control trial
Junhong Yu a, *, Iris Rawtaer b, Lei Feng a, Johnson Fam a, Alan Prem Kumar d,
Irwin Kee-Mun Cheah e, William G. Honer f, Wayne Su f, Yuan Kun Lee g, Ene Choo Tan h, i,
Ee Heok Kua a, Rathi Mahendran a, c, **
a
Department of Psychological Medicine, Mind Science Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b
Department of Psychiatry, Sengkang General Hospital, Singhealth Duke-Nus Academic Medical Centre, Singapore
c
Academic Development Department, Duke-NUS Medical School, 8 College Road, Singapore
d
Cancer Science Institute of Singapore, National University of Singapore, And Medical Science Cluster, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore
e
Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
f
Department of Psychiatry, University of British Columbia, Vancouver, Canada
g
Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University Hospital, Singapore
h
KK Research Laboratory, KK Women’s and Children’s Hospital, Singapore
i
SingHealth Duke-NUS Paediatrics Academic Clinical Program, Singapore

A R T I C L E I N F O A B S T R A C T

Keywords: Mindfulness-based interventions can enhance cognitive abilities among older adults, thereby effectively delaying
Mindfulness cognitive decline. These cognitive enhancements are theorized to accompany neuroplastic changes in the brain.
Meditation However, this mindfulness-associated neuroplasticity has yet to be documented adequately. A randomized
RCT
controlled trial was carried out among participants with mild cognitive impairment (MCI) to examine the effects
Cognitive enhancement
Attention
of a mindfulness-based intervention on various cognitive outcomes and cortical thickness (CT) in the context of
Cortical thickness age-related cognitive impairment. Participants were assigned to a mindfulness awareness program (MAP)(n =
Neuroplasticity 27) and an active control condition — health education program (n = 27). In both, they attended weekly sessions
Mild cognitive impairment for three months and subsequently, monthly sessions for six months. Cognitive assessments and structural scans
were carried out across three time-points. Whole brain analyses on CT were carried out and were supplemented
with region of interest-based analyses. ROI values and cognitive outcomes were analyzed with mixed MANOVAs
and followed up with univariate ANOVAs. Nine-month MAP-associated gains in working memory span and
divided attention, along with an increased CT in the right frontal pole and decreased CT in the left anterior
cingulate were observed. Three-month MAP-associated CT increase was observed in the left inferior temporal
gyrus but did not sustain thereafter. MAP led to significant cognitive gains and various CT changes. Most of these
neurobehavioral changes, may require sustained effort across nine months, albeit at a reduced intensity. MAP can
remediate certain cognitive impairments and engender neuroplastic effects even among those with MCI.

1. Introduction outcomes and functional independence (Gauthier, 2005). To this end,

the mild cognitive impairment (MCI) diagnostic entity conceptualized
Early treatment in dementia is crucial to maximizing treatment two decades ago, has been positioned as the intermediate stage between

* Corresponding author. Department of Psychological Medicine Yong Loo Lin School of Medicine, National University of Singapore MD1 Research Dry Laboratories
(North), #12-01, 12 Science Drive 2, 117549, Singapore.
** Corresponding author. Senior Consultant and Associate Professor, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University
of Singapore, NUHS Tower Block, Level 9, 1E Kent Ridge Road, 119228, Singapore.
E-mail addresses: pcmyj@nus.edu.sg (J. Yu), pcmrathi@nus.edu.sg (R. Mahendran).

https://doi.org/10.1016/j.jpsychires.2021.01.032
Received 21 February 2020; Received in revised form 23 December 2020; Accepted 16 January 2021
Available online 21 January 2021
0022-3956/© 2021 Elsevier Ltd. All rights reserved.
J. Yu et al.
Fig. 1. Consort flow diagram. MCI = mild cognitive impairment; MRI = magnetic resonance imaging; MAP = Mindfulness Awareness Program; HEP = Health
Education Program; AX = assessment.
healthy aging and dementia, in which researchers are optimistic that
interventions would alter the course of subsequent cognitive decline
(Petersen et al., 2014).
Among the non-pharmacological interventions that have been car­
ried out on the MCI population, there has been a growing interest in
mindfulness-based interventions (Chan et al., 2019). Although such in­
terventions traditionally target psychoaffective or behavioral issues
(Baer, 2003), evidence suggests that they can bring about a strong
cognitive enhancement effect (Chiesa et al., 2011) as well— which can
be exploited to delay subsequent cognitive decline. This is due to the fact
that meditation recruits several cognitive processes, which are trained
upon repeated sessions.
Mindfulness meditation generally involves focused attention and/or
open monitoring. In focused attention, the meditator has to direct and
sustain attention on an internal or external stimulus for a period of time.
In doing so, the meditator needs to constantly monitor his/her thoughts
to detect mind wandering. Occasionally, the meditator disengages from
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Journal of Psychiatric Research 135 (2021) 203–211
a distracting object (attention switching) and redirects attention to
another stimulus (selective attention)(Lutz et al., 2008). During open
monitoring, the meditator attends to the moment-by-moment experi­
ence in the ‘here and now’ in a nonjudgmental manner. In doing so,
he/she has to inhibit automatic cognitive appraisals and divert attention
away from distracting stimuli that would obscure attention to the
moment-by-moment experience (Jha et al., 2019). Essentially, medita­
tion can be thought of as a type of cognitive training for these different
cognitive abilities.
Alongside these training-related improvements, repeated sessions of
meditation may also trigger experience-dependent neuroplastic
changes. In this regard, one randomized controlled trial (RCT) assigned
healthy participants (i.e., self-reported to be psychologically and phys­
ically healthy, and not taking any medications) to a nine-session
Mindfulness-Based Stress Reduction (MBSR n = 16) intervention or a
wait-list control condition (n = 17) and compared the gray matter (GM)
changes between both groups. It was observed that the GM volumes in
J. Yu et al. Journal of Psychiatric Research 135 (2021) 203–211

Table 1 2. Material and methods

Characteristics of participants assigned to both treatment conditions.
MAP (N = HEP (N = Between-group 2.1. Design
27) 27) comparison

t χ2 p The study was carried out as an open-label RCT. Randomization was

stratified by gender and carried out in blocks of four using the Random
Mean age (SD) 71.3 (5.6) 71.4 (6.0) .12 .91
Sex
Allocation Software 2.0 by an independent researcher. The intervention
Male 8 6 .39 .54 consisted of two arms— mindfulness awareness program (MAP) and
Female 19 21 health education program (HEP). The latter was used as an active con­
Mean years of education (SD) 5.2 (4.9) 3.4 (4.3) 1.39 .17 trol condition for the former, to control for possible effects due to social
Mean MMSE score (SD) 24.6 (3.3) 24.7 (3.9) .11 .91
interaction. The intervention spans across nine months and consisted of
Mean sessions attendeda (SD)
First 3 months (12 sessions) 10.6 (1.5) 10.8 (1.4) .30 .77 two phases in both arms. During the first 3-month phase, sessions were
Subsequent 6 months (6 5.2 (1.5) 5.3 (1.2) .9 .93 held once per week for 12 sessions. Thereafter, these sessions took place
sessions) once per month in the subsequent 6-month phase. The rationale for
Note. MAP = Mindfulness awareness program; HEP = Health education pro­ dividing the intervention into two different phases of different treatment
gram; SD = standard deviation; MMSE = Mini-Mental State Examination. intensities was to assess if the treatment gains from the first phase can be
a
Among the analyzed longitudinal sample. sustained with much less time commitment from the participants in the
second phase. Each session would last for 45 min. The CONSORT flow
diagram of the study is shown in Fig. 1. Ethical approval for the current
Table 2 study was granted by a university’s institutional research board.
Cognitive outcomes assessed.
Test Outcomes Cognitive functions assessed 2.2. Participants
Semantic fluency test Number of unique Verbal fluency
animals Participants of the current study were recruited from the community,
Color trails test Interference effect Divided attention and set- as part of the larger Aging in a Community Environment Study cohort
switching (Feng, 2015). Details regarding the recruitment, which was carried out
Digit span subtests (WAIS- Digits forward total Working memory span
III) score
from 2011 to 2016 have been described elsewhere (Yu et al., 2016).
Digits backward total Working memory Subsequently, participants from this cohort were invited to participate
score manipulation in the current intervention study. The inclusion criteria were 1) aged
Rey Auditory Verbal Immediate recall Immediate memory between 60 and 85 (inclusive), 2) met the criteria for mild cognitive
Learning Test Delayed recall Delayed memory
impairment (MCI), 3) able to travel to the intervention venue indepen­
Delayed recognition Recognition memory
Block design test (WAIS- Total raw score Visuospatial processing dently, 4) not presenting with any current psychiatric or neurological
III) conditions, 5) not suffering from any terminal illness, 6) not partici­
pating in another interventional study and 7) for those undergoing
Note. WAIS-III = Wechsler Adult Intelligence Scale III.
magnetic resonance imaging (MRI) scans, not having any metallic body
implants (e.g., pacemaker), with the exception of dental implants.
left posterior cingulate cortex, left temporo-parietal junction, hippo­
The Petersen’s (2004) criteria were used for the MCI diagnosis. These
campus and bilateral regions in the cerebellum had increased in the
include subjective cognitive complaints as corroborated by a reliable
MBSR group as compared to the wait-list controls (Hölzel et al., 2011).
informant, presence of objective cognitive impairment and largely pre­
Another RCT (Pickut et al., 2013) compared 14 patients with Parkin­
served functional independence. In particular, the objective cognitive
son’s disease assigned to an eight-week mindfulness-based intervention
impairment criterion was operationalized as scoring 1.5 standard de­
and 13 patients on usual care, and found increased GM volume in the
viations (SD) below the age and education appropriate norms in any of
bilateral caudate nucleus, left occipital lobe, left thalamus and bilateral
six cognitive domains, as assessed via the digit span backward and block
temporo-parietal junction in the former group. A third RCT compared 12
design tests from Wechsler Adult Intelligence Scale (WAIS-III), delayed
college students assigned to a 4-week Sahaja Yoga meditation training
recall and recognition tests from the Rey Auditory Verbal Learning Test
with 30 wait-list controls and found meditation-associated GM increase
(RAVLT), Color Trails Test (CTT), and semantic fluency test. The MCI
in the right inferior frontal gyrus (Dodich et al., 2019). Additionally, two
diagnoses were made via a consensus from a panel of psychiatrists and
other RCTs (Tang et al., 2010; Wells et al., 2013) did not observe sig­
psychologists.
nificant meditation-associated GM changes. In general, the evidence on
Fifty-four participants were randomized into the two treatment
the neuroplastic GM changes associated with meditation has been
conditions. Information regarding their demographic characteristics,
limited and inconclusive.
general cognitive status and attendance are presented in Table 1. Inde­
In addition to replicating the previously documented meditation-
pendent samples t-tests suggest that both intervention groups were not
associated cognitive gains, we sought to make a meaningful contribu­
significantly different in terms of attendance in the two phases (ps ≥
tion to the limited pool of evidence relating to the meditation-associated
.77). Written informed consent was obtained from these participants
neuroplasticity. The current study evaluates the effect of a mindfulness-
prior to their participation. Among them, 51 had at least completed the
based intervention on various cognitive outcomes and GM cortical
first 3-month phase and 39 completed both phases. For the first three
thickness (CT) across a 9-month intervention period. We hypothesized
months, our calculations using G*Power indicated that the valid sample
that such intervention would engender significant cognitive gains,
size would provide a power of 0.80 (assuming an alpha level of 0.05 and
especially in the attentional domains, as well as increase CT in various
a 0.5 correlation between repeated measures) to detect a significant
cortical GM regions which were found to differ between experienced
Time * Group interaction if the true effect was at least 0.40 SD. Across
meditators and meditation-naïve controls.
the entire 9-month intervention period, our calculations using the same
parameters suggest that we can detect a true effect of at least 0.46 SD.
Considering that a recent meta-analysis (Chan et al., 2019) revealed a
much larger effect of meditation on global cognition among older adults
(SMD = 0.56), our sample sizes are more than adequate to detect the
hypothesized interaction effect on cognitive outcomes.

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J. Yu et al. Journal of Psychiatric Research 135 (2021) 203–211

Table 3
Results of the mixed ANOVA on cognitive outcomes from baseline to ninth month.
Cognitive outcome Time Group Time * Group

F p F p F p q η2partial
Digit span forward 3.50 0.069 0.01 0.914 8.01 0.007 0.060 0.18
Digit span backward 0.61 0.438 0.90 0.348 1.85 0.182 0.484 0.05
Immediate recall 7.00 0.012 3.65 0.064 0.40 0.533 0.849 0.01
Delayed recall 10.48 0.003 3.87 0.057 0.09 0.770 0.849 <.01
Recognition <.01 0.960 2.72 0.107 0.04 0.849 0.849 <.01
CTT - interference 1.58 0.217 3.03 0.091 5.03 0.031 0.126 0.13
Block design 11.17 0.002 2.27 0.140 0.28 0.600 0.849 <.01
Semantic fluency 0.91 0.348 0.47 0.495 0.12 0.732 0.849 <.01

Note. CTT = Color trails test; q = p values adjusted for false discovery rate.

2.3. Measures
Eight cognitive outcomes, indexing working memory span and
manipulation, divided attention, immediate, delayed and recognition
memory, verbal fluency and visuospatial processing from various tests
were administered (see Table 2). The procedures for these tests are
described in detail in the supplementary materials. For these measures,
higher scores correspond to better performance, with the exception of
the CTT interference, in which smaller interference scores relate to
better performance.
2.4. Intervention protocol
The MAP was modeled on similar group-based mindfulness medita­
tion for older adults (McBee, 2008) and was led by an experienced
instructor. Participants were taught 1) mindfulness of the senses
practice— to attend to the different senses (i.e., vision, hearing, touch)
to cultivate focused attention; 2) body scan practice— to develop kin­
esthesia by focusing their attention on various parts of their body as a
relaxation technique, while in a sitting and/or supine position; 3)
walking meditation practice— to cultivate calmness and momentary
concentration by walking slowly with mindfulness; 4) ‘movement nature
meant’ practice— to move with awareness for flexibility, strength and
confidence; and 5) visuomotor limb tasks that train one’s mind-body
coordination.
The weekly HEP didactic sessions were taught by an experienced
instructor, and covered topics such as chronic medical conditions (e.g.,
hypertension, diabetes, arthritis), medication compliance, and healthy
lifestyles (e.g., diet, nutrition, exercise, and relaxation). In the subse­
quent monthly discussion sessions, participants shared how they had
applied what they learned to their daily lives. Both programs were
separately carried out in a quiet room in a community location.
2.5. MRI acquisition
Participants were scanned in a 3-T Siemens Tim Trio scanner at the
Clinical Imaging Research Center, Singapore. T1-weighted images were
acquired using an MPRAGE protocol (TE = 1.90s; TR = 2.30s; TI = 900
ms; 256 × 256 matrix; 192 sagittal slices; in-plane resolution = 1 mm;
slice thickness = 1 mm).
2.6. Image preprocessing
T1-weighted images were preprocessed longitudinally using the
CAT12 (version r1450) as implemented in SPM12 (version 6225) within
MATLAB (R2019a). Baseline and follow-up images were rigidly real­
igned within-subject to correct for differences in head position and a
subject-specific average template was computed and used as reference in
a subsequent realignment of the baseline and follow-up images. The
realigned images were segmented into GM, white matter (WM) and
cerebrospinal fluid, as well as corrected for signal inhomogeneities with
reference to the subject average template. These GM and WM images
were used to estimate spatial normalization deformation fields using the
high dimensional Diffeomorphic Anatomic Registration Through Expo­
nentiated Lie Algebra (DARTEL) warping algorithm (Ashburner, 2007)
which were applied to segmented images and subsequently modulated.
These modulated images were then visually inspected.
Estimation of CT and the central surface was carried out using the
projection-based thickness method (Dahnke et al., 2013), which con­
sisted of topology correction (Yotter et al., 2011), spherical mapping,
and spherical registration (Yotter et al., 2011). After obtaining the
segmented images, WM distance was estimated and the local maxima
were projected to other GM voxels using a neighbor relationship
described by the WM distance (Dahnke et al., 2013). The ‘surface
thickness and thickness estimation for ROI’ writing option was used to
extract region-of-interest (ROI) values from the Desikan-Killiany atlas
(Desikan et al., 2006).
2.7. Statistical analyses
We were primarily interested in the treatment gains at the two
possible ‘exit points’ —third and ninth month, hence for the following
analyses we compared the outcomes between baseline and third month,
as well as between baseline and ninth month timepoints.
First, we carried out whole brain analysis on the preprocessed sur­
faced images. Two subjects (one from each treatment group) were
excluded from these analyses due to significant lesions. Then, treatment
effects were assessed using a flexible factorial GLM, modeling the three
factors of Subject, Group and Time, in which we examined the T con­
trasts for the Group * Time interaction (i.e., Timepost > Timepre & MAP
> HEP and Timepost > Timepre & MAP < HEP). The results were
thresholded using p < 0.05, family-wise error (FWE) correction against a
null-distribution generated by 5000 nonparametric permutations using
the TFCE toolbox, with a cluster extent threshold of k > 20. Significant
clusters are labeled using the Desikan-Killiany atlas.
Given the relatively small number of scanned participants, a whole
brain analysis was unlikely to yield multiple clusters that would survive
the stringent FWE corrections. Hence, we supplemented the whole brain
analyses with ROI-based analyses. Specifically, we selected on an a
priori basis, ROIs that corresponded to the significant cortical GM
clusters identified in a meta-analysis that compared between experi­
enced meditators and meditation naïve controls (Fox et al., 2014). These
included the bilateral regions of the anterior cingulate cortex (ACC),
orbitofrontal cortex (OFC), frontal pole (FP) and insula. Apart from the
first two, these ROIs were extracted as they were parcellated in the atlas.
The ACC ROI was created by summing the caudal and rostral anterior
cingulate ROIs, and the OFC ROI was created by summing the lateral and
medial orbitofrontal ROIs. These ROIs were entered into subsequent
analyses together with the cognitive outcomes.
For the analyses of the cognitive outcomes and CT ROIs, in order to
minimize the false positive results associated with multiple testing,
multivariate analyses of variance (MANOVA) were carried out sepa­
rately on the cognitive outcomes and CT ROIs, with time and group as
the within- and between-subject factors, respectively, to determine the

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J. Yu et al.
Fig. 2. Trajectories of cognitive outcomes in each group across time. The thick colored lines represent the mean trajectory of each group, which are enclosed within
their respective 95% confidence intervals. *p < .05; **p < .01.
overall effect on the assessed outcomes. In line with our general
analytical framework, the MANOVAs compared between baseline and
third month, as well as between baseline and ninth month timepoints. If
significant group*time interaction effects were obtained in any of these
MANOVAs, post hoc univariate analyses of variance (ANOVA) were
carried out individually on each outcome between the respective time­
points. Although it is possible to analyze all three timepoints in a single
MANOVA and proceed with post hoc analyses, we did not do so. This is
because the valid sample size at the ninth month timepoint is much
smaller, given that the three-timepoint MANOVA can only be carried out
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Journal of Psychiatric Research 135 (2021) 203–211
on participants with valid data on all three timepoints, such analyses
would discard several participants with incomplete ninth month data,
ultimately reducing statistical power. Effect sizes for the significant
statistics relating to the time * group interactions were quantified using
partial eta square (η2partial), where η2partial of 0.06 and 0.13 indicates
medium and large effect sizes, respectively. Statistical significance was
set at p < .05. For the post-hoc ANOVAs, we have additionally computed
p-values adjusted for false discovery rate (FDR). Nevertheless, we do not
expect the significant results of these ANOVAs to survive such correc­
tions, as this would require very large treatment effects and sample sizes
J. Yu et al.
Table 4
Results of the mixed ANOVA on the regions-of-interest from baseline to ninth month.
Regions-of-interest Time Group
F p F p
Anterior cingulate L 0.20 0.658 0.13
Anterior cingulate R 0.01 0.924 0.01
Orbitofrontal L 0.52 0.479 0.02
Orbitofrontal R 0.91 0.351 0.11
Frontal pole L 0.92 0.349 0.68
Frontal pole R 0.15 0.704 0.01
Insula L 1.63 0.217 0.08
Insula R 3.44 0.079 0.22
Note. L = Left; R = Right; q = p values adjusted for false discovery rate.
that are beyond what is expected or practical for this study. These an­
alyses were carried out R 4.0.2. The R code for executing these analyses
and generating the figures are available at https://osf.io/ykz2c/files/.
3. Results
3.1. Effect of MAP on cognitive outcomes
The MANOVAs revealed a significant Time * Group effect on
cognitive outcomes between the baseline and ninth month (F(8, 28) =
1.92; p = .022; η2partial = 0.44),but not between baseline and third month
(F(8, 39) = 1.92; p = .106; η2partial = 0.27). Thus, univariate ANOVAs
were carried out to follow up on the significant effects between the
baseline and ninth month. The detailed results of all modeled effects in
these ANOVAs are presented in Table 3. In these post hoc analyses,
significant Time*Group interactions emerged for digit span forward and
CTT interference. Fig. 2 showed that the digit span forward score and
CTT interference among MAP participants had increased and decreased,
respectively over time, relative to their HEP counterparts. As expected,
none of these significant post-hoc results survived the FDR correction.
3.2. Effect of MAP on cortical thickness
The MANOVAs on the CT revealed a significant Time * Group effect
between baseline and ninth month (F(8, 12) = 3.03; p = .041; η2partial =
0.67), but not between baseline and third month (F(8, 29) = 2.01; p =
.080; η2partial = 0.36). Univariate ANOVAs were carried out to follow up
on the significant effects between baseline and ninth month. The
detailed results of all modeled effects in these ANOVAs are presented in
Table 4.These ANOVAs revealed a significant Time * Group on the right
FP (F(1, 19) = 5.19; p = .035; η2partial = 0.21) and left ACC (F(1, 19) =
5.18; p = .035; η2partial = 0.21). Fig. 3 showed that, relative to HEP
participants, the CT in the right FP and left ACC among MAP participants
had increased and decreased, respectively, across this period. None of
these significant post-hoc results survived the FDR correction. Addi­
tionally, none of the CT changes in any ROIs were significantly corre­
lated with any of the changes in cognitive outcomes. The descriptive
statistics of the ROI CT values across the three time-points are reported
in the supplementary materials (see table S2).
Next, CT was analyzed at the whole brain level. Across the first three
months, whole brain analyses within the contrast of Time3-month >
Timebaseline & MAP > HEP revealed a significant cluster in the left
inferior temporal gyrus (ITG)(k = 28, peak level FWE-corrected p =
.009; MNI = − 55, − 33, − 24; see Fig. 4a). No significant clusters
emerged in the reverse contrast (i.e., Time3-month > Timebaseline & MAP
< HEP). Across the entire 9-month intervention period, no significant
clusters were observed in any of the interaction contrasts. The uncor­
rected statistical maps of these contrasts are presented in the supple­
mentary materials (see figures S1 and S2). Given these results, there is a
possibility that the significant cluster obtained from the first 3-month
period did not appear in the subsequent 6-month period, merely due
to the reduced sample size. Hence, we investigated this further by
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Journal of Psychiatric Research 135 (2021) 203–211
Time * Group
F p q η2partial
0.718 5.18 0.035 0.138 0.21
0.913 0.01 0.921 0.921 <.01
0.898 0.04 0.848 0.921 <.01
0.747 0.80 0.381 0.844 0.04
0.419 0.03 0.855 0.921 <.01
0.936 5.18 0.035 0.138 0.21
0.784 0.16 0.695 0.921 <.01
0.647 0.67 0.422 0.844 0.03
extracting the significant cluster as an ROI and entering these ROI values
into a mixed ANOVA. The Time * Group effect across the entire 9-month
intervention period was not significant (F(1, 36) = 0.21; p = .649;
η2partial = 0.01 see Fig. 4b), in contrast to the significant interaction across
the first three months (F(1, 19) = 23.27; p < .001; η2partial = 0.39).
4. Discussion
The current study examined the effects of a mindfulness-based
intervention on cognitive outcomes and CT. In the cognitive domain,
we observed a gradual improvement in working memory span and
divided attention among MAP participants relative to their HEP coun­
terparts, culminating in medium to large effect sizes across the entire 9-
month intervention period. As for CT, MAP participants, relative to their
HEP counterparts had significantly increased CT, as quantified by a large
effect size, in the right FP across the entire 9-month intervention period.
At the end of the first 3-month phase, the CT in MAP participants had
significantly increased in a left ITG cluster, as quantified by a large effect
size, relative to HEP participants. However, these 3-month MAP-
associated CT changes in the left ITG did not sustain until the ninth
month. Overall, these results suggest that the MAP intervention led to
significant cognitive gains and neuroplastic changes across the 9-month
intervention period.
With repeated sessions of meditation, our MAP participants trained
their abilities to engage and disengage their attention on various stimuli.
Naturally, the effect of such attentional training would transfer to our
measure of divided attention, where participants had to repeatedly
engage and disengage between two sets of stimuli (i.e., pink and yellow
circles in the CTT). Furthermore, we observed MAP-associated working
memory improvements as measured by the digit span forward. Gener­
ally, working memory span benefits from an improved attention. A
larger working memory span can be the result of a greater ability to
control attention to avoid distraction and thereby maintain more stored
items (Engle, 2002). Such controlled attention was practiced in our MAP
as participants focused and sustained their attention on various external
and interoceptive stimuli. However, we did not observe a similar
MAP-associated improvement for working memory manipulation as
measured by the digit span backward. Although meditation typically
involves the manipulation information in the working memory, such
manipulation is largely restricted to the engagement and disengagement
of information in the present moment without judgment or elaboration
(Jha et al., 2019). Arguably, this involves a relatively low cognitive load.
Our measure of working memory manipulation requires elaborate pro­
cessing of information— to reverse the order of the digits while holding
these digits in the working memory. Essentially, for the digit span
backward, working memory is being tested while being weighed down
by an additional cognitive load. This is not something our MAP partic­
ipants would have had more practice with than their HEP counterparts.
In terms of MAP-associated neuroplasticity, we observed some CT
changes which are consistent with previous findings. First, there was a
significant MAP-associated increase in the CT of the left ITG (at least
within the first three months) and right FP. A meta-analysis (Fox et al.,
J. Yu et al.
Fig. 3. Trajectories of cortical thickness values in each group across time. The thick colored lines represent the mean trajectory of each group, which are enclosed
within their respective 95% confidence intervals. *p < .05.
2014) that compared between experienced meditators and medi­
tation-naïve controls had observed similar clusters of GM volume in­
crease in the right frontopolar cortex (including the FP) and left ITG.
Relatedly, task-based functional MRI studies have shown that activa­
tions in the frontopolar cortex (Molenberghs et al., 2016) and the left
ITG (Hasenkamp et al., 2012) were linked to meditation-associated
meta-cognitive processes, such as meta-cognitive judgments and
awareness of mind wandering. Given this, the MAP-associated CT in­
creases in these regions could speculatively be linked to the enhanced
meta-cognitive abilities typically brought about via repeated sessions of
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Journal of Psychiatric Research 135 (2021) 203–211
meditation. As our intervention transitioned from weekly to monthly
sessions, it was observed that the increased CT in the left ITG, were no
longer sustained at the ninth month. Perhaps, this suggests that the
monthly meditation sessions were not adequate to maintain such gains.
It is plausible that if our intervention had continued its weekly sessions,
greater neuroplastic changes and perhaps cognitive gains would be
observed. Indeed, a meta-analysis on mind-body exercises observed that
interventions with more frequent sessions were more likely to result in
greater cognitive gains than those of less frequent sessions (Chan et al.,
2019).
J. Yu et al.
Fig. 4. a) Significant cluster (FWE-corrected p < 0.05) in left inferior temporal gyrus within the contrast of Time3-month > Timebaseline & MAP > HEP. b) trajectories
of cortical thickness values of extracted cluster in each group across time. The thick colored lines represent the mean trajectory of each group, which are enclosed
within their respective 95% confidence intervals. ***p < .001.
In contrast to previous cross-sectional studies that found increased
ACC GM volume among experienced meditators (Fox et al., 2014), we
observed a MAP-associated CT decrease in the ACC. Notwithstanding,
the problems of comparing the current intervention results to
cross-sectional findings, this decrease in ACC CT or volume should not
always be viewed negatively, especially since the ACC is involved in
several functions. One such function includes emotional processing
(García-Cabezas and Barbas, 2016). In relation to this, a lesion study
(Tolomeo et al., 2016) suggests that the removal of the anterior cingu­
late may be therapeutic for patients with intractable mood, anxiety and
pain syndromes, specifically in terms of reducing negative affect.
Relatedly, we speculate that the reduced ACC CT among MAP partici­
pants may reflect the neuroplastic changes corresponding to the
MAP-associated attenuations in emotional reactivity to negative affect
(Britton et al., 2012).
These findings present important implications in the clinical context.
We have shown that a relatively low intensity (i.e., weekly or monthly
sessions) non-pharmacological intervention can result in significant
cognitive gains and neuroplastic changes in the context of age-related
cognitive impairment. In essence, our intervention would be instru­
mental in delaying further cognitive decline or even enhancing one’s
functional status, without the side-effects of medications (Smith, 2016)
or exhaustion associated with intensive cognitive training (Vranic,
2017). Additionally, the MAP-associated cognitive gains were mostly
observed within the domains of executive-attention. This would suggest
that such mindfulness-based interventions would be more appropriate
for older adults with executive-attentional impairments, such as those
with nonamnestic MCI or at risk for frontotemporal dementia, than
those with amnestic MCI or at risk for Alzheimer’s disease. It should also
be noted that while the targeted cognitive gains are most relevant to this
group of older adults, their executive functions deficits may bring about
some difficulties during meditation, especially when they are required to
sustain and focus their attention for a period of time.
The current study is subjected to a few limitations. First, this was an
open-label study, in which both participants and the experimenters were
aware of which treatment group the former was assigned to. There is a
small possibility that the results may be confounded by observer-
expectancy effects among experimenters and the differences in partici­
pants’ treatment expectancies between both groups. Second, the attri­
tion rate for MRI data was quite significant; by the ninth month, the
number of acquired scans was less than half of that at baseline. This
limits the study’s ability to detect significant treatment effects on CT
during the subsequent 6-month phase. Given that this attrition was
largely due to various physical and psychological discomforts during the
scans, future studies should attempt to alleviate some of these
210
Journal of Psychiatric Research 135 (2021) 203–211
discomforts in order to retain as many MRI-eligible participants as
possible, especially among the older adult population.
CRediT authorship contribution statement
Junhong Yu: Writing - original draft, Formal analysis, Software,
Visualization. Iris Rawtaer: Writing - original draft. Lei Feng: Writing -
review & editing. Johnson Fam: Writing - review & editing. Alan Prem
Kumar: Formal analysis, Writing - review & editing. Irwin Kee-Mun
Cheah: Writing - review & editing. William G. Honer: Writing - re­
view & editing. Wayne Su: Software, Formal analysis, Writing - review
& editing. Yuan Kun Lee: Writing - review & editing. Ene Choo Tan:
Writing - review & editing. Ee Heok Kua: Writing - review & editing,
Funding acquisition. Rathi Mahendran: Writing - review & editing,
Funding acquisition, Project administration, Supervision.
Declaration of competing interest
None.
Acknowledgement
We acknowledge the contributions of the following: the Late Mr Wee
Sin Tho for developing and structuring the Mindfulness Program for this
study and Dr Goh Lee Gan for developing and delivering the Health
Education Talks
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpsychires.2021.01.032.
Financial support
This work was supported by Research Donations from Kwan Im
Thong Hood Cho Temple and Lee Kim Tah Holdings Pte Ltd under the
Mind Science Center, Department of Psychological Medicine, National
University of Singapore.
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Another random document with
no related content on Scribd:
 Vertat vt in brutum de racione virum:
Ex oculis primum dabis, vt retinere secundum
Possis, dum causam lex regit ipsa tuam.
Causidici nubes sunt ethera qui tenebrescunt,508
Lucem quo solis nemo videre potest:
Obfuscant etenim legis clarissima iura,
Et sua nox tetra vendicat esse diem;
Istis inque viris perdit sua lumina splendor,
230 Verum mentitur, fraus negat esse fidem.
Lex furit et pietas dormit, sapiencia fallit,
Pax grauat, et lites commoda queque ferunt:
Et sic lex legis a ledo ledis in isto,
Et ius a iurgo, tempore iura legit.
Vnio set populi firmo si staret amore,
Causidici vanus tunc foret ille status.
Est bona lex in se fateor, tamen eius inique
Rectores video flectere iura modo.
Non licet, vt dicunt, quod conspiracio fiat,
240 Non tamen hoc faciunt quod sua iura docent:
Contra causidicum si quid michi lex det agendum,
Et peto consilium iuris habere meum,
Tunc dicunt alii, nolunt obstare sodali;
Sic ledunt, set eos ledere nemo potest.
Sic sibi causidicus mundi perquirit honores,
Subuertens lingue iura vigore sue:
Castiget reliquos lex quos vult, non tamen ipsos,
Quos deus aut mundus nescit habere probos.

Hic loquitur qualiter isti causidici et iuris

aduocati, in sua gradatim ascendentes
facultate, Iudicisque aspirantes officium,
iudicialis solii tandem cacumen attingunt; vbi
quasi in cathedra pestelencie509 sedentes,
maioris auaricie cecitate percussi, peioris quam
antea condicionis existunt.
Capm. iiii. Est Apprenticius, Sergantus post et Adultus,
250 Iudicis officium fine notabit eum.
Si cupit in primo, multo magis ipse secundo,
Tercius atque gradus est super omne reus;
Et sic lex grauibus auri moderatur habenis,
Quod modo per iustas non valet ire vias.
Libera qualis erat lex non est, immo ligatam
Carcere nummorum ceca cupido tenet:
Aurea ni clauis dissoluerit ostia clausa,
Eius ad introitum nullus habebit iter.
Nil manus in pulsu, nil vox clamore iuuabunt
260 Te cum lege loqui, qui sine claue venis:
Dux tibi si nummus non sit, conducat et ipse
Custodes legis, cassus abire potes.
Et sic causidicus causam, iudex neque iustum
Iudicium cernit, dux nisi nummus erit.
Sunt tria precipue, quibus est turbacio legis,
Vnde sui iuris perdit vbique locum;
Munus, amicicia, timor, hec tria iure negante
Pacta ferunt, quod eis obstat in orbe nichil.
Dicit enim Salomon oculos quod Iudicis aurum
270 Cecat, et est racio contaminata lucro;
Scimus et hoc omnes, qui iudicis extat amicus,
Perdere iudicio nil valet ipse suo.
Nouimus hoc eciam, tangat si causa potentem,
Cernere iusticiam dat timor inde fugam;
Horrendasque minas iudex non sustinet ipsas,
Sepius et precibus flectitur absque minis:
Litera magnatis dum pulsat iudicis aures,
Tollit vis calami debita iura sequi.
Set super omne modo sibi ve, qui pauper egendo
280 Quid petit in lege, dum nequit ipse dare!
Publica sunt ista nobis, quod lege moderna
Pauperis in causa ius negat acta sua.
Sic ego non video mea que sunt, set dubitando
Auribus attonitis quero cauenda malis.
Ecce dies in qua, fuerat que iuris amica,
 Nunc magis econtra lex gerit acta sua:
Larua tegit faciem, confundit glosaque textum,
Vertit et in logicam lex variata scolam;
Absque tamen numero sunt legis in orbe scolares,
290 Plurima sunt folia, fructus et inde minor.
Nomine sub iusto quam sepe nephanda parantur,
Subque dolus facie plurima iuris agit:
Qui magis in causis discernunt talibus orbem,
Crimina sunt cautis ista timenda viris.
Grandia per multos tenuantur flumina riuos,
Alueus et sterilis sic vacuatur aquis:
Pluribus expensis patitur thesaurus eclipsim,
Fit, nisi preuideat, sepeque diues inops:
Sic humus ista breui ditissima tempore pauper,
300 Excessus legum ni moderetur, erit.
Tollere nodosam nescit medicina podagram,
Sic nec auaricie lex medicamen habet.
Est mea bursa potens, lex inde subacta silebit,510
Preueniens auro singula iura fugo:
Aut si magnatis michi curia sit specialis,
Nil opus est legum viribus, ipse loquor.
Continuata diu sic vlcerat illa cicatrix,
Non habet vlterius iam noua plaga locum.

Hic loquitur quasi per epistolam Iudicibus

illis directam, qui in caduca suarum diuiciarum
multitudine sperantes, deum adiutorem suum
ponere nullatenus dignantur.

Capm. v. O qui iudicia vite mortis quoque rerum

310 Clauditis in manibus appreciata lucris,
De qua iusticia vosmet saluare putatis,
Cum sit lex aliis vendita vestra dolis?
O dilectores mundi falsique potentes,
Terre quique deos esse putatis opes,
O qui mundanos sic affectatis honores,
 Est quibus assidua sollicitudo comes,
Discite precipitem quia sepius ardua casum
Expectant que leui mobilitate cadunt.
Sepius alta cadit ventorum flatibus arbor,
320 Planta satis placido permanet atque gradu:
Aerias alpes niuibus candescere scimus,
Quas subito torquent frigus et omne gelu;
Est ibi ventorum rabies seuissima, dumque
Temperiem gratam proxima vallis habet.
Sic vobis numquam desunt aduersa, potentes,
Nec pax est vobis certa nec vlla quies.
Dic michi diuitibus si quando defuit hostis:
Quin magis hos quassat sepe ruina grauis.
Non dat securos nec ebur nec purpura sompnos,
330 Paupertas vili stramine tuta iacet:
Perdere quo possunt, torquet timor omnis auaros,
Vanaque sollicitis incutit vmbra metus.
Auri possessor formidat semper, et omnem
Ad strepitum fures estimat esse prope;
Arma, venena timet, furtum timet atque rapinas,
Fiduciam certam diues habere nequit.
Hunc, dum querit opes, cruciat miseranda cupido,
Cum iam quesitas cepit habere, timor.
Sic igitur miser est, dum pauper querit habere,
340 Et miser est diues, perdere dumque timet.
Dum iacet in plumis, vigilans mens aspera sentit,
Feruet enim variis exagitata dolis:
Dicit, ‘Habere volo vicini pauperis agrum,
Est etenim campus proximus ille meis.’511
Sic fugat a domibus pupillos iste paternis,
Insequitur viduas iudiciisque premit:
Deliciis fruitur de rebus pauperis iste,
Dampna set alterius computat esse nichil.
Si posset mundum lucrari, quis deus esset,
350 Vlterius scire nollet in orbe deum.
Iudex, nonne tui fulgor tibi sufficit auri,
Vt careat tenebris mens tua ceca tuis?
 Aproprias aurum tibi fertile, nec tamen vmquam512
Ad sterilem vitam respicis ipse tuam.
Iusticie montes Iudex vix ardua purus
Scandit, dum mundi rebus onustus erit.
Agrorum fines longos extendere queris,
Nec reputas vite tempora curta tue.
Quid petis argentum tibi? spem quid ponis in
aurum?
360 Sunt nam communes omnibus orbis opes.
Sepius ista dei data conspicis hostibus esse,
Ante deum nulla laus et habetur eis:
Ista paganus habet, Iudeus, latro cruentus;
Crede quod iratus sepe dat ista deus.
Parua puto, quecumque malos contingit habere,
Non est prauorum copia grande bonum.
O quociens vir iustus eget, scelerosus habundat,
Hic set non alibi, ius quia regnat ibi.
Dilectus domini moritur, dum viuit adulter,
370 Non tamen hii Cristi sunt in amore pares:
Egrotat iustus, dum sanus floret iniqus,
Fine tamen proprium quisque reportat onus.
Si tamen in mundo iudex sibi ferre salutem
Possit, non curat quid sibi finis erit.
O qui cuncta cupis, cur temet deseris? Omne
Est quod in orbe tenes, set neque temet habes.
O qui scis alios non te, tu notus ad omnes,
Non tibi quid prodest illa sciencia, nil.
Te noscas igitur primo, me nosce secundo,
380 Rectum iudicium sic sapienter age.
Omnia que mundi sunt diligis, omnia Cristi
Linquis, et ex nichilo credis habere satis:
Tu celum perdis, mundum lucraris, inane
Corpus supportas, spiritus vnde cadit.
Est tibi perfectum vanum, tibi mobile firmum,
Talis enim iudex non bene sentit opus:
Edificas turres, thalamos nouitate politos,
Quicquid et est orbis plus deitate colis:
 Edificas ampla, fossa clauderis in arta,
390 Quo medium frontis ostia clausa prement.
Quid vestes referam, lectos vel iudicis edes,
Quorum luxuries nescit habere pares?
Qui modo prospiceret habitacula queque fuerunt,
Alterius nouiter diceret illa Iouis.
Gloria nonne tuis erit aut tibi pompa perhennis,
Quas facis in domibus, dum tua lucra rapis?
En cecidit Babilon, cecidit quoque maxima Troia,
Romaque mundipotens vix tenet illa locum.
Omnis habet subitum mundana potencia finem,
400 Atque fuga celeri deserit ipsa suos:
Iudex, ergo time, magnos qui scandis honores,
Teque ruinoso stare memento loco.
Omne quod est mundi tibi carum transiet a te,
Inque tuis meritis iudicat ipse deus:
Equaque lex domini tunc que modo cernis
ineque513
Discernet, que tibi pondera iusta dabit.
Cum te terribilis exactor missus ab equo
Iudice sulphurei merget in yma laci,
Prodolor! infelix tunc, quamuis sero, dolebis,
410 Talibus in falsis spem posuisse bonis:
Gemma vel argentum nec ibi descendet et aurum,
Nec fragilis mundi gloria lapsa breui.
Iudicibus populi vanum tamen est quod in ista
Materia scripsi; perdita verba dedi:
Que nam iusticia, que vel sit Iudicis equa
Condicio, non est tempore visa modo:
Iusticiarius est; sub tali nomine fallit,
Qui sine iusticia nomen inane gerit.

Hic loquitur de errore Vicecomitum,

Balliuorum, necnon et in assisis iuratorum, qui
singuli auro conducti diuitum causas iniustas
 supportantes, pauperes absque iusticia
calumpniantur et opprimunt.

Capm. vi. Nunc eciam vicecomitibus quid dicere possum?

420 Numquid in assisis dant nocumenta viris?
Macra fit hec causa, de qua viget vnccio nulla
Distillans, vt eis vncta sit inde manus:
Legis in assisa si sint tua dona recisa,
Ius perit et causa scinditur inde tua;
Si tamen assessa sint pre manibus tua dona,
Tunc potes assisis sumere lucra tuis.
Vtque bouem, precio qui stat conductus aratro,
Sic tibi iuratos munere ferre vales:
Hii tibi proque tuis vendent periuria nummis,
430 Sic aurum iura vincit in vrbe mea:514
Diuitis iniustam causam sic cerno quietam,
Et iustam causam pauperis esse ream.
Non comes a vice, set vicio comes accipit ortum,
Iuris auaricie fert tamen ipse vices.
Sic dico vicecomitibus, quod munere victi
Communi populo dant nocumenta modo:
Nec sibi iurati sapiunt quid, sit nisi lucri,
De sale conditum quod dabis ante manum:
Causidici lanam rapiunt, isti quoque pellem
440 Tollunt, sic inopi nil remanebit oui.
Sic ego legiferis concludens vltima primis,
Dico quod ex bursa lex viget ecce noua;
Vt margaritas si porcus sumat in escas,
Sumunt legiferi sic modo iura sibi.
Vendere iusticiam quid id est nisi vendere
Cristum,515
Quem Iudas cupido vendidit ipse dolo?
Numquid adhuc Iude similis quis viuit in orbe?
Immo sibi plures viuere credo pares.
Namque semel Iudam talem committere culpam
450 Nouimus, hunc et eo penituisse lego;
 Nunc tamen vt merces vendunt communiter
omnes,
Gaudentes lucrum sic habuisse suum.
Rettulit hoc precium Iudas quod cepit iniqum,
Nec liquet hinc veniam promeruisse suam:
Nunc erit ergo quid hiis, vendunt qui iura sinistris,
Est quibus hora fori cotidiana quasi?516
Vt vorat et stricte tenet ipsa vorago gehenne,
Nec redit vllus homo liber ab ore suo,
Sic modo qui vendunt leges que premia carpunt,
460 Hec valet a manibus tollere nemo suis;
Et quia sic similes inferno suntque tenaces,
Credo quod infernus fine tenebit eos.
Quid seu Balliuis dicam, qui sunt Acherontis
Vt rapide furie? Tu magis inde caue.
Quo portas intrant, prenostica dampna figurant,
Cunctis namque viis ve comitatur eis.
Vt Crati bufo maledixit, sic maledico
Tot legum dominis et sine lege magis.

Hic loquitur quod sicut homines esse super

terram necessario expedit, ita leges ad eorum
regimen institui oportet, dummodo tamen legis
custodes verum a falso discernentes vnicuique
quod suum est equo pondere distribuant. De
erroribus tamen et iniuriis modo contingentibus
innocenciam Regis nostri, minoris etatis causa,
quantum ad presens excusat.517

Capm. vii.Pro transgressore fuerant leges situate,

470 Quilibet vt merita posset habere sua:
Nunc tamen iste bonus punitur, et alter iniqus,
Dum viget ex auro, iustificatur eo.
Omnia tempus habent et habet sua tempora
tempus,
Causaque sic causas debet habere suas.
 Quid mare conferret, altis dum fluctuat vndis,
Sit nisi nauis ei quam vehit vnda fluens?518
Set quid fert nauis nisi nauta regens sit in illa?
Quid valet aut nauta, si sibi remus abest?
Quid mare, quid nauis, quid nauta, vel est sibi
remus,
480 Sit nisi portus aquis ventus et aptus eis?
Gens sine lege quid est, aut lex sine iudice quid
nam,
Aut quid si iudex sit sine iusticia?
In patria nostra si quis circumspicit acta,
Hec tria cernet ibi sepe timenda michi.
Omnia dampna grauant, set nulla tamen grauiora,
Quam cum iusticiam iustus habere nequit.
Ex iniusticia discordia crescit, et inde
Cessat amor solitus, murmurat atque domus:
Murmur si veniat, venit et diuisio secum,
490 Terraque diuisa non bene stabit ea;
Et quodcumque sit hoc per se quod stare nequibit,
Ve sibi, nam subito corruet absque modo.
Testis enim deus est, dicens quod regna
peribunt519
In se diuisa, credoque dicta sua.
Ergo videre queunt quotquot qui regna gubernant,
Nostre pars sortis maxima spectat eis.
Quicquid delirant reges, plectuntur Achiui,
Nam caput infirmum membra dolere facit:
Dux si perdat iter, errant de plebe sequentes,
500 Et via qua redient est dubitanda magis.
Propter peccatum regis populi perierunt,
Quicquid et econtra litera raro docet;
Regia set bonitas fert plebi gaudia pacis,
Nam deus ad sancti regis agenda fauet:
Si viciosus enim sit rex, quia lex nequit, ipsum
Vult punire deus, qui super omne potest.
Expediens populo foret vt bene viueret omnis
Rex, iacet in manibus sors quia bina suis:
 Vna salus populi rex qui bene viuit habetur,
510 Plebis et in pestem rex malus acta parit;
Eius enim scelera constat magis esse nociua,
Cuius habent populi condita iura sequi.
Cum sit maior homo, sunt plus sua crimina
tanto;
Dum cadit ex altis, leditur inde magis.
Plures cerno reos, magis attamen omnibus ipsos,
Legiferi qui sunt et sine lege manent.
Cum sine lege furit regni viciata potestas,
Esse nichil toto tristius orbe potest:
Sanccius esse pecus animoque capacius ipso
520 Estimo, qui iura dat neque seruat ea.
Imperium Regis non solum bella triumphis
Ornant, set leges seruet vbique bonas.520
Nonne domus poterit componere se sine lignis;
Set sibi quid ligna, si nec acuta foret?
Set quid acuta valet, nisi persistens operantis
Vnitis causis sit manus artificis?
Hec sibi si fuerint coniuncta, per omne iuuabunt,
Et si diuisa, pars sibi nulla iuuat.
Terra quid est sola, populus nisi sistat in illa?
530 Quid populus ve sibi, rex nisi regnet ibi?
Est quid rex, nisi consilium fuerit sibi sanum?
Sunt quid consilia, rex nisi credat ea?
Attamen in nostra sic stat diuisio terra,
Quod sibi quisque suam iam legit ire viam:
Conciues hodie discordia vexat in vrbe,
Extinguit quod ius quilibet alterius;521
Nec lex campestris est iam memorata magistris,
Set qui plus poterit, ipse magister erit.
Nunc clerus populum, populus culpat quoque
clerum,
540 Et tamen in culpa perstat vterque sua:
Invidus alterius nunc culpat quemlibet alter,
Parsque suum proprium nulla reformat iter.
Si videas vtrumque statum, dices quia certe
 In magnis lesi rebus vterque sumus.

Nunc magis i n s p e c i e v o x p l e b i s
clamat vbique
Pectore sub timido que metuenda
fero.
Curia que maior defendere iura
t e n e t u r,
Nunc magis iniustas ambulat ipsa
vias:
Infirmo capite priuantur membra
salute,
Non tamen est medicus qui modo
550 curat opus.
Est ita magnificus viciorum morbus
abortus,
Quod valet excessus tollere nulla
manus:
Sic oritur pestis, per quam iacet
obruta virtus,
Surgit et in vicium qui regit omne
forum.
Rex, puer indoctus, morales
n e g l i g i t a c t u s ,522
In quibus a puero crescere possit
homo:
Sic etenim puerum iuuenilis concio
ducit,
Quod nichil expediens, sit nisi
velle, sapit.
Que vult ille, volunt iuuenes sibi
consociati,
I l l e s u b i n t r a t i t e r, h i i q u e s e q u n t u r
560 eum:
Va n u s h o n o r v a n o s i u u e n e s f a c i t
esse sodales,
 Vnde magis vane regia tecta
colunt.
Hii puerum regem puerili more
subornant,
Pondera virtutum quo minus ipse
gerit.
Sunt eciam veteres cupidi, qui
lucra sequentes
Ad pueri placitum plura nephanda
s i n u n t :523
Cedunt morigeri, veniunt qui sunt
viciosi,
Quicquid et est vicii Curia Regis
habet.
Error ad omne latus pueri
consurgit, et ille,
Qui satis est docilis, concipit omne
570 malum:
Non dolus immo iocus, non fraus
set gloria ludi
Sunt pueris, set ei sors stat aborta
doli.
Sunt tamen occulte cause, quas
nullus in orbe
Scire potest, set eas scit magis
ipse deus:
Nescit enim mater nato que fata
p a r a n t u r,
Fine set occultum clarius omne
patet.
Ta l i a v o x p o p u l i c o n c l a m a t v b i q u e
moderni
In dubio positi pre grauitate mali:
Sic ego condoleo super hiis que
tedia cerno,
Quo Regi puero scripta sequenda
580 fero.
545-580 Text SCEHGDL As follows in TH₂

Nunc magis ecce refert verbi clamantis ad

aures524
Vox, et in hoc dicit tempore plura grauant.
Crimen et, vt clamat, fert maius curia maior,
Que foret instructor, legibus extat egens.
Ad commune bonum non est <modo> lingua
locuta,525
550* Immo petit proprii commoda quisque lucri.
Agmen adulantum media procedit in aula,
Quodque iubet fieri, curia cedit eis:526
Set qui vera loqui presumunt, curia tales
Pellit, et ad regis non sinit esse latus.
Stat puer immunis culpe, set qui puerile
Instruerent regimen, non sine labe manent:
Sic non rex set consilium sunt causa doloris,
Quo quasi communi murmure plangit humus.
Tempora matura si rex etatis haberet,
560* Equaret libram que modo iure caret:
Regis namque modus alios moderatur, et
omnis527
Iuris ad officium dicitur esse caput.
Si bonus esse velit rex, hii qui sunt bonitatis
Sunt magis edocti condicione bona:528
Si malus esse velit, simili rex sorte clientes,
Vt sibi complaciant, eligit, ornat, amat:529
Hoc set eum tangit discretum quem probat etas,
Non puerum, quia tunc fit sibi culpa minor
Non est nature lex nec racionis, vt illud
570* Quod mundum ledit sit puerile malum;
Non dolus, immo iocus, non fraus set gloria ludi,
Sunt pueris, nec ibi restat origo mali.
Dixit enim Daniel, quod de senioribus orta
 Exiit impietas, quam furor orbis habet:
Omne quod est mundi vicium plantant veterani,
Et quasi de peste spersa venena serunt.530
Horum namque scelus fertur maculare figuras
Tocius mundi, quo furit ira dei.
Iamque supercreuit dolus et defecit honestas,531
580* Sentit et opprobrium quod fuit ante decus.

Hic loquitur quod, exquo omnes quicumque mundi status

sub regie magestatis iusticia moderantur, intendit ad presens
r e g n a t u r o532 i a m Regi nostro quandam epistolam
d o c t r i n e c a u s a533 editam scribere consequenter, ex qua
ille rex noster, qui modo in sua puerili constituitur etate, cum
vberiores postea sumpserit annos, gracia mediante diuina, in
suis regalibus exercendis euidencius instruatur. Et primo dicit
quod, quamuis regalis potencia quodammodo supra leges
extollatur, regiam tamen decet clemenciam, quod ipse bonis
moribus inherendo, quasi liber sub iusticie legibus se et suos in
aspectu Regis altissimi assidue gubernet.

Capm. viii. Cumque sui Regis legi sit legius omnis

Subditus, et toto corpore seruit ei,
Est ita conueniens quod eum de corde fideli
Mentis in affectu legius omnis amet:
Regis et est proprium, commissam quod sibi
plebem
Dirigat, et iusta lege gubernet eam.
Hinc est, quod normam scriptis de pluribus ortam
Regis ego laudi scribere tendo mei.
O pie rex, audi que sit tua regula regni,
590 Concordans legi mixtaque iure dei.
Legum frena tenens freno te forcius arce;
Dum nullum metuis, sis metus ipse tibi:
 Namque timor, virtus humilis, fugit omne
superbum,
Et quasi virtutum clauiger esse solet.
Est tibi, rex, melius quod te de lege gubernes,
Subdere quam mundi singula regna tibi:
Est propter mundum tibi subdita sors aliorum,
Tu propter celum subditus esto deo.
Vt tibi deseruit populus de lege subactus,
600 Cristi seruiciis temet ad instar habe:
Vincere te studeas, alios qui vincis, et omnes
Excessus animi subdere disce tui:
Iustificans alios cupias te iustificare,
Iuraque dans plebi, des ita iura tibi.
Qui superas alios, temet superare labora;
Si rex esse velis, te rege, rex et eris.
Qua fore se regem poterit racione fateri,
Mentis qui proprie non regit acta sue?
Non valet hoc regimen aliis conferre salutem,
610 Dum sibi non fuerit rector, vt esse decet.
Dum tibi cuncta licent, ne queras cuncta licere,
Res etenim licite noxia sepe ferunt:
Tu super es iura, iustus set viue sub illis,534
Spesque tui nobis causa salutis erit.
Est mors ira tua, potes id quod non licet, et te
Prestita vota tamen ducere iuris habent:
Quod licet illesa mentis precordia seruat,
Omne tamen licitum non probat esse probum:
Quod licet est tutum, set que potes illa sub arto
620 Discute iudicio fultus honore tuo.
Micius acta regas, aliter nisi causa requirat;
Asperitas odium seuaque bella mouet.
Non te pretereat populi fortuna potentis
Publica, set sapiens talia fata caue.
Vita Pharaonis et gesta maligna Neronis,
Que iusto regi sunt fugienda docent.
O bone rex iuuenis, fac quod bonitate iuuentus
Sit tua morigeris dedita rite modis.
 Quid tibi forma iuuat vel nobile nomen Auorum,
630 Si viciis seruus factus es ipse tuis?
Doctor Alexandri Magni prauos sibi mores
Primitus edocuit, dum puer ipse fuit:
Rex puer hec didicit, que post dum dedidicisse
Temptauit, primus obstat abusus ei:
Vicit Alexander Darium simul et Babilonem,
Set nequit impressum vincere corde malum.
Nuper in exemplis scripserunt sic sapientes,
Quod prius imbuerit, testa tenere solet:
Rex, igitur cicius viciosos pelle remotos,
640 Nam vix turpe vetus nescit abire foras.
Plaude bonis, fuge prauorum consorcia, labem
De pice tractata contrahit egra manus.

Hic loquitur qualiter rex535 sibi male

consulentes caucius euitare, proditoresque
regni sui penitus extinguere, suorum eciam
conditiones ministrorum diligencius
inuestigare, et quos extra iusticiam errantes
inuenerit, debita pena corrigere debet et
districcius castigare.

Capm. ix. Sordibus implicitos falsosque cauebis amicos,

Qui tua deposcunt, te nec amare volunt:
Blanda dolosorum fugias per verba leuari,
Ne speciale tuum nomen ad yma ruant:
Verba nimis leuiter audire que credere dicta
Sepe supervacuos cogit inire metus.
Vir qui bella mouet, qui predas consulit, et qui
650 Conspirat taxas plebis habere tue,
O rex, oro tuas quod claudas talibus aures,
Ne tua nobilitas lesa fatiscat eis.536
Consilium regale tuum vir nullus auarus
Tangat, set tales mortis ad instar habe.
 Illud in orbe malum non est, q u o d c o r d i s
auari
Non latet in cella, dum sitit inde lucrum:
Ambulat in tenebris, opus exercet tenebrarum,
Odit et impugnat nil nisi pacis opus.537
Qui mel in ore gerens, set habens in corde
venenum,
660 Pacis habet verbum, mente notando malum,
Hic est versutus, inimicis regis amicus,
Semper venalis, dum vacat ipse lucris;
Vipereum genus et vanum plenumque veneno,538
Fraudibus, insidiis, artibus arma parat:
Semper in insidiis sedet incautisque nocere
Temptat, et occulto fabricat ipse dolos.
Hic rimans animos hominum secreta reuelat,
Et similis Iude fabricat acta sua.
Qui te sollicitat, rex, et subuertere temptat,
670 Qui te persuadet soluere iussa dei,
Quis sit et ipse vide, qualis vel condicionis,
Aut tibi si vera dicere verba velit.
Discute mente prius animum temptantis, et audi
Si vel constanter vel dubitanter agat,
Si tibi preponat dubium, mendacia fingens:
Semper deprendi verba dolosa timent.
Cum sit causa doli, pie rex, tu credere noli,
Si quis agat praue, tu sua facta caue.
Multus non credit, nisi cum res noxia ledit;539
680 Ante manum sapiens prouidet acta regens:
Decipiuntur aues per cantus sepe suaues;
Blande, rex, lingue mellea verba fuge.
Rex, bona digna bonis da premia, rex, et iniquis
Que sua promeruit premia culpa dabis:
Latro bonus veniam Cristo miserante meretur,
Penam promeruit in cruce latro malus.
Obsequium prauum trahit e manibus graue
donum,
Que sunt facta suo fine notabit homo.
 Si scelus vlcisci racio certissima poscit,
690 Iustus in hoc casu quod decet illud age.
Ficta tibi pietas non mulceat aspera iuris,
Vlcio iudicium compleat immo tuum:
Sepe pericla fera fert iudicis vlcio tarda,
Destruit ille bonos qui sinit esse malos.
Diuersas penas diuersis addito culpis,
Mille mali species, mille salutis erunt.
Iudicii signum gladius monstrare videtur,
Proditor vt periat, rex tenet arma secus:540
Rex iubeat tales laqueo super alta leuari,
700 Ne periat Regis legis et ille status.541
Rex, age, ne plebis furiens discordia dicat,
‘Lex caruit rege iura paterna regens’:
Absit et hoc vulgo ne dicat, iure remoto,
Quod nichil auxilii principis vmbra facit.
Fraus cum fraude sua periat de morte remorsa,541
Vt stet iusticia regia laude tua:
Sic dicant populi, ‘Sit semper gloria regi,
Quo bona pax viguit, quo reus acta luit.’
Precipitur gladius vibratus semper haberi,
710 Prompcius vt crimen iudiciale ferat:
Ense quiescente, compescere non valet orbem;
Qui regnare cupit sanguine iura colat.
Arma ferunt pacem, compescunt arma rapacem,
Vt reus hec timeat, rex probus arma gerat;
Nomine subque tuo ledant ne forte quirites,
Plebem te tenero corde videre decet:
Si vis namque tuos non castigare ministros,
Crimen habet culpe regia culpa sue.
Euolat ancipiter ad predas, lucra suisque
720 Deseruit dominis in rapiendo cibos:
Sic sunt qui regi famulando suos et ad vsus
Tollunt pauperibus dampna ferendo nimis.
In prece pondus habet pauper qui clamat egenus
Ad dominum, memor est pauperis ipse sui.
Sicut enim presul, qui custos est animarum,
 Pondus in officio debet habere suo;
Compotus vtque suus, sic stabit et vltima merces,
Gloria vel pena perpetuatur ei;
Rex ita qui nostrum moderaris legibus orbem,
730 Dona tuis meritis conferet equa deus.
Posse tuum grande, rex, est, que potencior ille,
Omne tuum cuius dextera librat opus.

Hic dicit quod rex sano consilio adhereat,

ecclesie iura supportet et erigat,542 equs in
iudiciis et pietosus existat, suamque famam
cunctis mundi opibus preponat.

Capm. x. Sperne malos, cole prudentes, compesce

rebelles,
Da miseris, sontes respue, parce reis.
Quicquid agas, vicio numquam mergatur
honestum;
Fama lucro, rebus preficiatur opus.
Nil tibi, rex, fingas pro mundo, quo reputeris
Iustus apud proceres et reus ante deum:
Ecclesiam studeas multa pietate fouere,
740 Cuius enim precibus vult diadema geri.
Pauperis et vidue dum cernis adesse querelas,
Iudicium miseris cum pietate geras.
Expedit interdum sanccita remittere legum,543
Ne periat pietas de feritate tua:
Indulgere tuis tua sic dignetur honestas,
Nam puto sepe deum viuere velle reum.
Par quoque portet onus sic nobilis atque colonus,
Et nichil archanum polluat ante manum.
Ardua si causa tibi sit, videas, quia certe
750 Tarda solet magnis rebus inesse fides.
Rebus in ambiguis tu certum ponere noli,
Fallitur augurio spes bona sepe suo:
Est magis humani generis iactura dolori,
 Nescit principium quid sibi finis aget.
Dum tibi suadet opus tractare negocia regni,
Consilium regat hoc cum seniore senex.
Ibit in occasum quicquid dicemus ad ortum,
Lingua loquax habitum nesciat ergo tuum.
Consilium prauum regalem turbat honorem,
760 Prouocat inque scelus que bona pacis erant.
Iura dabit populo senior, discretaque iustis
Legibus est etas vnde petatur honor.
Est satis ille senex, cuius sapiencia sensum
Firmat in etate, sit licet ipse minor.
Non stabiles animos veteres fatuam ve
iuuentam544
Comprobo, non etas sic sua iura dedit:
In sene multociens stat condicio iuuenilis,
Dum iuuenis mores obtinet ipse senis.
Caucius ergo statum videas, pie rex, ad vtrumque;
770 Vnde legas homines, tu prius acta proba.
Qui tibi seruicium prebet nec invtilis aurum
Appetit, hic seruus debeat esse tuus:
Dulcius est mercede labor qui regis honorem
Spectat, et in tali spem tibi ferre potes.
Est qui pacificus, est vir qui iuris amicus,
Liber auaricie, largus ad omne bonum,
Vtere consilio tali, pie rex, vt habundet
Cronica perpetue laudis in orbe tue.
Fama volans gratis, nullo soluente cathenas,545
780 Proclamat meritis ista vel illa tuis:
Nomen, crede, bonum gasas precellit, honorem
Conseruat, remouet scandala, laude viget:
Tange bonum florem, dulcem prestabit odorem,
Sic virtusque viri fragrat vbique boni.
Consule doctores legis, discede malorum
A conventiculis, concomitare bonos:
Vt granum de messe tibi, de fonte salubri
Pocula, de docto dogmata mente legas.