Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis

Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials

Mindfulness-based interventions (MBIs) are increasingly being delivered through the Internet. Whereas numerous meta-analyses have investigated the effectiveness of face-to-face MBIs in the context of mental health and well-being, thus far a quantitative synthesis of the effectiveness of online MBIs is lacking. The aim of this meta-analysis was to estimate the overall effects of online MBIs on mental health. Fifteen randomised controlled trials were included in this study. A random effects model was used to compute pre-post between-group effect sizes, and the study quality of each of the included trials was rated. Results showed that online MBIs have a small but significant beneficial impact on depression (g=0.29), anxiety (g=0.22), well-being (g=0.23) and mindfulness (g=0.32). The largest effect was found for stress, with a moderate effect size (g=0.51). For stress and mindfulness, exploratory subgroup analyses demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, meta-regression analysis showed that effect sizes for stress were significantly moderated by the number of intervention sessions. Effect sizes, however, were not significantly related to study quality. The findings indicate that online MBIs have potential to contribute to improving mental health outcomes, particularly stress. Limitations, directions for future research and practical implications are discussed.

Trauma Therapists' Clinical Applications, Training, and Personal Practice of Mindfulness and Meditation

Mindfulness and meditation (MM) are increasingly used in trauma treatment, yet there is little research about therapist qualifications and clinical applications of these practices. We surveyed trauma therapists (N = 116) about their clinical uses, training, and personal practice of MM. Most respondents reported use of MM in trauma therapy, primarily MM-related imagery and breathing exercises and mindfulness in session or daily life. Almost a third used mindfulness-based stress reduction, mindfulness-based cognitive therapy, or mindfulness-based relapse prevention. Across all respondents, 66 % were trained by a mental health (MH) professional, 16 % were trained exclusively by a spiritual teacher, and 18 % received no training. On average, therapists used four types of MM. Less than half maintained a personal meditation practice and only 9 % reported practicing daily meditation. Therapists who were trained by a MH professional were more likely to integrate MM into trauma psychotherapy; those who were trained by a spiritual teacher were more likely to teach clients to use MM between sessions and reported more personal practice of MM. Results indicate divergence from standard recommendations for therapist personal practice and professional training in manualized uses; however, there is little guidance about requisite training and personal practice to support individualized uses of MM such as breathing exercises and imagery. Further research should address relationships of therapist training and personal practice to clinical outcomes in MM-informed trauma therapy.

Revalidation of the Cognitive and Affective Mindfulness Scale — Revised (CAMS-R) With Its Newly Developed Chinese Version (Ch-CAMS-R)

Considering the strengths and weaknesses of currently available inventories measuring mindfulness for Chinese population, a need for a short and comprehensive inventory was identified. The present study therefore developed a written Chinese version of the Cognitive and Affective Mindfulness Scale — Revised (CAMS-R) that excels in its full range of conceptual coverage, employs widely accessible language, and is brief in length. The reliability and validity of the Ch-CAMS-R was examined and found to be compatible with the original version and with other inventories measuring mindfulness. Results of confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) suggested allocation of two question items, without posing a threat to the four-factor (including attention, awareness, present-focus and acceptance) structure in both the CAMS-R and Ch-CAMS-R. In general, the present study supports that this four-factor structure is compatible with the conceptualidation of mindfulness in both United States and Hong Kong samples.

Higher emotional intelligence is related to lower test anxiety among students

BACKGROUND

For students attending university courses, experiencing test anxiety (TA) dramatically impairs cognitive performance and success at exams. Whereas TA is a specific case of social phobia, emotional intelligence (EI) is an umbrella term covering interpersonal and intrapersonal skills, along with positive stress management, adaptability, and mood. In the present study, we tested the hypothesis that higher EI and lower TA are associated. Further, sex differences were explored.

METHOD

During an exam week, a total of 200 university students completed questionnaires covering sociodemographic information, TA, and EI.

RESULTS

Higher scores on EI traits were associated with lower TA scores. Relative to male participants, female participants reported higher TA scores, but not EI scores. Intrapersonal and interpersonal skills and mood predicted low TA, while sex, stress management, and adaptability were excluded from the equation.

CONCLUSION

The pattern of results suggests that efforts to improve intrapersonal and interpersonal skills, and mood might benefit students with high TA. Specifically, social commitment might counteract TA.

Mindfulness- and Acceptance-based Interventions for Psychosis: A Systematic Review and Meta-analysis

Background:

Mindfulness- and acceptance-based interventions are increasingly studied as a potential treatment for a variety of mental conditions.

Objective:

To assess the effects of mindfulness- and acceptance-based interventions on psychotic symptoms and hospitalization in patients with psychosis

Methods:

MEDLINE/PubMed, Embase, the Cochrane Library, and PsycINFO were screened from inception through April 2015. Randomized controlled trials (RCTs) were analyzed when they assessed psychotic symptoms or hospitalization in patients with psychosis; affect, acceptance, mindfulness, and safety were defined as secondary outcomes.

Results:

Eight RCTs with a total of 434 patients comparing mindfulness-based (4 RCTs) or acceptance-based interventions (4 RCTs) to treatment as usual or attention control were included. Six RCTs had low risk of bias. Moderate evidence was found for short-term effects on total psychotic symptoms, positive symptoms, hospitalization rates, duration of hospitalization, and mindfulness and for long-term effects on total psychotic symptoms and duration of hospitalization. No evidence was found for effects on negative symptoms, affect, or acceptance. No serious adverse events were reported.

Conclusion:

Mindfulness- and acceptance-based interventions can be recommended as an additional treatment for patients with psychosis.

Review: Effectiveness of mindfulness in improving mental health symptoms of children and adolescents: a meta-analysis

BACKGROUND

Mindfulness-based interventions (MBIs) are increasingly used in the management of various mental health disorders in children and adolescents. However, there is limited evidence about the efficacy of various interventions used.

METHOD

A systematic review was performed to examine the effects of different MBIs on mental health symptoms and quality of life in both clinical and nonclinical samples of children and adolescents using data from only randomized control trials. The studies were also assessed for quality. Based on the type of MBI, study population, and control arm we had three comparisons for meta-analyses.

RESULTS

Fifteen studies were included in the qualitative analysis but only 11 trials with comparable interventions and controls were included for meta-analyses. Mindfulness-based stress reduction/mindfulness-based cognitive therapy arm was more effective than nonactive control in the nonclinical populations. Acceptance commitment therapy was comparable to active treatments in patients in the clinical range. Other MBIs were also effective improving anxiety and stress but not depression in nonclinical populations compared to nonactive control.

CONCLUSIONS

Mindfulness-based interventions can be effective in children and adolescents with mental health symptoms. As there were significant limitations these results must be interpreted with caution.

Evaluating Nonattachment and Decentering as Possible Mediators of the Link Between Mindfulness and Psychological Distress in a Nonclinical College Sample

Although increasing evidence shows that mindfulness is positively related to mental health, the nature and mechanisms of this relationship are not fully understood. Based on previous research findings and suggestions, the authors of the current study hypothesized that decentering and nonattachment are 2 variables that mediate the relationship between mindfulness and psychological distress. A nonclinical, non-treatment-seeking sample of 308 students and employees from a middle-class, primarily Caucasian university filled out mindfulness, decentering, nonattachment, and mental distress measures online. Mediational analyses failed to support the hypothesis. Results suggest that mindfulness and nonattachment are independent predictors of nonclinical psychological distress and fully explain the effect of decentering on psychological distress. Results should be interpreted with caution and not generalized to clinical issues. A more comprehensive look into the mechanisms of mindfulness, especially with rigorous experimental, longitudinal studies, is warranted. The authors stress the importance of checking alternative, equivalent models in mediation studies.

Facing the fear of failure: An explorative qualitative study of client experiences in a mindfulness-based stress reduction program for university students with academic evaluation anxiety

The aim of this qualitative study was to investigate the subjective experiences of 29 university students who participated in an 8-week mindfulness-based stress reduction (MBSR) program for academic evaluation anxiety. Participants who self-referred to the Student Counseling Service underwent individual semi-structured interviews about how they experienced the personal relevance and practical usefulness of taking the MBSR program. Interviews were transcribed and analyzed through a team-based explorative–reflective thematic approach based on a hermeneutic-phenomenological epistemology. Five salient patterns of meaning (themes) were found: (1) finding an inner source of calm, (2) sharing a human struggle, (3) staying focused in learning situations, (4) moving from fear to curiosity in academic learning, and (5) feeling more self-acceptance when facing difficult situations. We contextualize these findings in relation to existing research, discuss our own process of reflexivity, highlight important limitations of this study, and suggest possible implications for future research.

Exploring Occupational Therapists' Perceptions of the Usefulness of Musculoskeletal Sonography in Upper-Extremity Rehabilitation

OBJECTIVE

To identify the potential utility of musculoskeletal sonographic imaging in upper-extremity rehabilitation.

METHOD

Two occupational therapists in an outpatient hand rehabilitation clinic were recruited by convenience, were trained in the use of sonography, and implemented sonographic imaging in their clinical practice. Qualitative data were obtained during and after the implementation period by means of questionnaires and interviews. Data collection, analysis, and interpretation were completed in an iterative process that culminated in a thematic analysis of the therapists' perceptions.

RESULTS

The data indicate four potential areas of utility for musculoskeletal sonography in upper-extremity rehabilitation: (1) mastering anatomy and pathology, (2) augmenting clinical reasoning, (3) supplementing intervention, and (4) building evidence.

CONCLUSION

Numerous potential uses were identified that would benefit both therapist and client. Further exploration of complexities and efficacy for increasing patient outcomes is recommended to determine best practices for the use of musculoskeletal sonography in upper-extremity rehabilitation.

Challenges to Enrollment and Participation in Mindfulness-Based Stress Reduction Among Veterans: A Qualitative Study

BACKGROUND

Mindfulness-Based Stress Reduction (MBSR) is associated with reduced depressive symptoms, quality of life improvements, behavioral activation, and increased acceptance among veterans. This study was conducted to increase the reach and impact of a veterans' MBSR program by identifying barriers to enrollment and participation to inform modifications in program delivery.

OBJECTIVE

Verify or challenge suspected barriers, and identify previously unrecognized barriers, to enrollment and participation in MBSR among veterans.

DESIGN

A retrospective qualitative analysis of semistructured interviews.

SETTING/LOCATION

VA Puget Sound Health Care System (Seattle, WA).

SUBJECTS

68 interviewed, and 48 coded and analyzed before reaching saturation.

APPROACH

Content analysis of semistructured interviews.

RESULTS

Of the participants who enrolled, most (78%) completed the program and described MBSR positively. Veterans identified insufficient or inaccurate information, scheduling issues, and an aversion to groups as barriers to enrollment. Participants who discontinued the program cited logistics (e.g., scheduling and medical issues), negative reactions to instructors or group members, difficulty understanding the MBSR practice purposes, and struggling to find time for the practices as barriers to completion. Other challenges (cohort dynamics, teacher impact on group structure and focus, instructor lack of military service, and physical and psychological challenges) did not impede participation; we interpreted these as growth-facilitating challenges. Common conditions among veterans (chronic pain, posttraumatic stress disorder, and depression) were not described as barriers to enrollment or completion.

CONCLUSIONS

Women-only MBSR groups and tele-health MBSR groups could improve accessibility to MBSR for veterans by addressing barriers such as commute anxiety, time restrictions, and an aversion to mixed gender groups among women. Educating MBSR teachers about veteran culture and health challenges faced by veterans, adding psychoeducation materials that relate mindfulness practice to conditions common among veterans, and improving visual aids for mindful movement exercises in the workbook could better accommodate veterans who participate in MBSR.

A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses

BACKGROUND

Levels of stress and burnout increase during nursing education. This development has consequences for nursing students' health, learning, competence, and interest in quality issues in health care.

DESIGN

In a randomized controlled pilot trial with a sample of 113 nursing students the effect of an intervention using techniques from acceptance and commitment training (ACT) to prevent the development of stress and burnout was evaluated.

METHOD

The 6 × 2-hour program was compared to standard treatment (reflection seminars) post-intervention and at a three-month follow-up using longitudinal analysis of mean response profiles. Mechanisms of change were investigated using a baseline-post intervention two-mediator model.

RESULTS

The intervention resulted in increased mindful awareness and decreased experiential avoidance, as well as decreased perceived stress and burnout. Levels of mindful awareness and perceived stress were sustained at follow-up. The proposed mechanisms of change were partly supported by the data.

CONCLUSION

This study shows that techniques from ACT might have the potential to contribute to preventing the development of stress and burnout during nursing education. However, additional studies are needed to validate these results.

The preparatory set: a novel approach to understanding stress, trauma, and the bodymind therapies

Basic to all motile life is a differential approach/avoid response to perceived features of environment. The stages of response are initial reflexive noticing and orienting to the stimulus, preparation, and execution of response. Preparation involves a coordination of many aspects of the organism: muscle tone, posture, breathing, autonomic functions, motivational/emotional state, attentional orientation, and expectations. The organism organizes itself in relation to the challenge. We propose to call this the "preparatory set" (PS). We suggest that the concept of the PS can offer a more nuanced and flexible perspective on the stress response than do current theories. We also hypothesize that the mechanisms of body-mind therapeutic and educational systems (BTES) can be understood through the PS framework. We suggest that the BTES, including meditative movement, meditation, somatic education, and the body-oriented psychotherapies, are approaches that use interventions on the PS to remedy stress and trauma. We discuss how the PS can be adaptive or maladaptive, how BTES interventions may restore adaptive PS, and how these concepts offer a broader and more flexible view of the phenomena of stress and trauma. We offer supportive evidence for our hypotheses, and suggest directions for future research. We believe that the PS framework will point to ways of improving the management of stress and trauma, and that it will suggest directions of research into the mechanisms of action of BTES.

EEG-guided meditation: A personalized approach

The therapeutic potential of meditation for physical and mental well-being is well documented, however the possibility of adverse effects warrants further discussion of the suitability of any particular meditation practice for every given participant. This concern highlights the need for a personalized approach in the meditation practice adjusted for a concrete individual. This can be done by using an objective screening procedure that detects the weak and strong cognitive skills in brain function, thus helping design a tailored meditation training protocol. Quantitative electroencephalogram (qEEG) is a suitable tool that allows identification of individual neurophysiological types. Using qEEG screening can aid developing a meditation training program that maximizes results and minimizes risk of potential negative effects. This brief theoretical-conceptual review provides a discussion of the problem and presents some illustrative results on the usage of qEEG screening for the guidance of mediation personalization.

Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial

BACKGROUND

Individual-based cognitive-behavioural therapy (CBT) is in short supply and expensive.

AIMS

The aim of this randomised controlled trial (RCT) was to compare mindfulness-based group therapy with treatment as usual (primarily individual-based CBT) in primary care patients with depressive, anxiety or stress and adjustment disorders.

METHOD

This 8-week RCT (ClinicalTrials.gov ID: NCT01476371) was conducted during spring 2012 at 16 general practices in Southern Sweden. Eligible patients (aged 20-64 years) scored ≥10 on the Patient Health Questionnaire-9, ≥7 on the Hospital Anxiety and Depression Scale or 13-34 on the Montgomery-Åsberg Depression Rating Scale (self-rated version). The power calculations were based on non-inferiority. In total, 215 patients were randomised. Ordinal mixed models were used for the analysis.

RESULTS

For all scales and in both groups, the scores decreased significantly. There were no significant differences between the mindfulness and control groups.

CONCLUSIONS

Mindfulness-based group therapy was non-inferior to treatment as usual for patients with depressive, anxiety or stress and adjustment disorders.

Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans

INTRODUCTION

Anxiety, depression, and pain are major problems among veterans, despite the availability of standard medical options within the Veterans Health Administration. Complementary and alternative approaches for these symptoms have been shown to be appealing to veterans. One such complementary and alternative approach is mindfulness-based stress reduction (MBSR), a brief course that teaches mindfulness meditation with demonstrated benefits for mood disorders and pain.

METHODS

We prospectively collected data on MBSR's effectiveness among 79 veterans at an urban Veterans Health Administration medical facility. The MBSR course had 9 weekly sessions that included seated and walking meditations, gentle yoga, body scans, and discussions of pain, stress, and mindfulness. Pre-MBSR and post-MBSR questionnaires investigating pain, anxiety, depression, suicidal ideation, and physical and mental health functioning were obtained and compared for individuals. We also conducted a mediation analysis to determine whether changes in mindfulness were related to changes in the other outcomes.

RESULTS

Significant reductions in anxiety, depression, and suicidal ideation were observed after MBSR training. Mental health functioning scores were improved. Also, mindfulness interacted with other outcomes such that increases in mindfulness were related to improvements in anxiety, depression, and mental health functionality. Pain intensity and physical health functionality did not show improvements.

DISCUSSION

This naturalistic study in veterans shows that completing an MBSR program can improve symptoms of anxiety and depression, in addition to reducing suicidal ideations, all of which are of critical importance to the overall health of the patients.

Mindfulness and Physical Activity

Mindfulness and mindful activity can have a profound effect on physical and mental health. When considering mindfulness and physical activity, it is important to differentiate between physical activities, which are geared toward mindfulness and have mindful components, for example, yoga, platies, and tai chi, from other mindfulness interventions that are then geared toward greater awareness and mindfulness, which may then lead to healthful behavior change such as increasing physical activity. Prescribing mindfulness interventions may be another resource to help physicians when interacting with their patients, considering motivating patients to exercise and become more physically active can be challenging. Engaging in mindfulness can elicit change over time. Integrating mindfulness to interventions with exercise is one way to initiate exercise adherence as well as improve self-efficacy. When practicing mindful-based exercise programs, the benefits can also be seen with improved breathing rate and depth, heart rate, and parasympathetic activity. Promoting mindfulness-based training for physical activity has positive effects both psychologically and physiologically.

A new look at the science of weight control: how acceptance and commitment strategies can address the challenge of self-regulation

The current manuscript proposes an acceptance-based, self-regulation framework for understanding the challenge of weight maintenance and describes how this framework can be integrated into the behavioral treatment of obesity. According to this framework, intrinsic drives to consume palatable, high-calorie food interact with a modern environment in which high calorie foods are easily accessible. This combination produces a chronic desire to eat unhealthy foods that exists in opposition to individuals' weight control goals. Similarly, low energy expenditure requirements reduce physical activity. We suggest that individuals vary in their responsivity to cues that motivate overeating and sedentary behavior, and that those higher in responsivity need specialized self-regulatory skills to maintain healthy eating and exercise behaviors. These skills include an ability to tolerate uncomfortable internal reactions to triggers and a reduction of pleasure, behavioral commitment to clearly-defined values, and metacognitive awareness of decision-making processes. So-called "acceptance-based" interventions based on these skills have so far proven efficacious for weight control, especially for those who are the most susceptible to eating in response to internal and external cues (as predicted by the model). Despite the current empirical support for the postulated model, much remains to be learned including whether acceptance-based interventions will prove efficacious in the longer-term.

Mindfulness-based relationship education for couples expecting their first child--part 1: a randomized mixed-methods program evaluation

This article is Part 1 of a two-part series, in which we report on our evaluation of a mindfulness-based relationship enhancement program for couples who are expecting their first child. In this mixed-methods randomized clinical trial, we assigned 33 couples to the 4-week Mindful Transition to Parenthood Program treatment group (n = 16 couples) or to a waitlist control condition (n = 17 couples). Men in the treatment group significantly improved in relationship satisfaction, mindfulness, and negative affect; women had no significant treatment effects. Small to large effect sizes were present for treatment group men and women in multiple areas. Mixed-methods analyses demonstrated that this intervention may be especially helpful for men because of differences in social support needs, effects of program enrollment, and relational processes in the prenatal period.

Towards a better understanding of caregiver distress in early psychosis: a systematic review of the psychological factors involved

OBJECTIVES

We sought to review empirical studies of psychological factors accounting for distress in caregivers of young people with early psychosis.

METHOD

Following the PRISMA guidelines, we included studies that empirically tested psychological models of caregiver distress in early psychosis by searching the following databases up until March 2014: PsycINFO, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL). This was followed by additional manual searches of reference lists and relevant journals.

RESULTS

The search identified 15 papers describing 13 studies together comprising 1056 caregivers of persons with early psychosis. The mean age of caregivers was 47.2years (SD=9.8), of whom 71.5% were female and 74.4% were parents. Nine different psychological variables were examined in the included studies, which were categorised in the following non-mutually exclusive groups: coping, appraisal/attribution and interpersonal response. There was considerable data to support the link between distress and psychological factors such as avoidant coping, appraisal and emotional over-involvement. However, the possibilities of drawing conclusions were limited by a number of methodological issues, including cross-sectional data, small sample sizes, confounding variables not being accounted for, and a wide variation in outcome measures.

DISCUSSION

The strengths of the review were the systematic approach, the exclusion of non-empirical papers and the rating of methodological quality by two independent raters. Limitations were that we excluded studies published in languages other than English, that data extraction forms were developed for this study and hence not tested for validity, and that there was a potential publication bias in favour of significant findings.

CONCLUSION AND IMPLICATIONS

A better grasp of the psychological factors accounting for caregiver distress early in the course of illness may help us understand the trajectory of distress. This is an important step in preventing long-term distress in caregivers and supporting recovery in the whole family.

Group, One-on-One, or Internet? Preferences for Mindfulness Meditation Delivery Format and their Predictors

OBJECTIVES

Group mindfulness meditation interventions have improved symptoms in many health conditions. However, many people are unwilling to receive group treatment, so alternative delivery methods such as individual and internet may be a useful option. The study objective was to examine mindfulness meditation intervention delivery format preferences and their relationship to potential predictors.

DESIGN

An online survey was conducted of adult English speakers. Data was collected on interest and preference for internet, individual, or group formats of a mindfulness meditation intervention. Age, gender, personality, and posttraumatic stress disorder score and status and depression status were also collected.

RESULTS AND CONCLUSIONS

500 eligible participants completed the survey (mean age 39±15; range 18-70; 68% female). Participants were more interested in the Internet (n=356) and individual formats (n=384) than the group format (n=245). Fifty-five participants (11%) said they would refuse a group format. Internet was the first choice format for most participants (Internet 212 (43%), Individual 187 (38%), Group 97 (20%) and group was the last choice for most participants (Internet 140 (29%), Individual 70 (14%), Group 279 (57%)). Age, extraversion and emotional stability were significant in predicting first choice format. These results support the need for more research and implementation of alternative mindfulness meditation intervention delivery formats. Future research will incorporate additional predictors and include a broader range of participants.

The efficacy of mindfulness-based cognitive therapy as a public mental health intervention for adults with mild to moderate depressive symptomatology: a randomized controlled trial

OBJECTIVE

Although there has been growing evidence for the efficacy of mindfulness-based cognitive therapy (MBCT) for different clinical populations, its effectiveness as a public mental health intervention has not been studied. The present study evaluates a community-based MBCT intervention for adults with mild to moderate depressive symptomatology in a large multi-site, pragmatic randomized controlled trial.

METHOD

The participants with mild to moderate depressive symptomatology were recruited from the general population and randomized to the MBCT intervention (n = 76) or to a waiting list control group (n = 75). Participants completed measures before and after the intervention. Participants in the experimental condition also completed these measures at a 3-month follow-up.

RESULTS

In the experimental condition significant reductions in depression, anxiety, and experiential avoidance, and improvements in mindfulness and emotional- and psychological mental health were found, compared to the waiting list (effect sizes Cohen's d = 0.31-0.56). These effects were sustained at the 3-month follow-up. The likelihood of a clinically significant change in depressive symptoms was significantly higher for the MBCT group [odds ratio (OR) 3.026, p<0.01 at post-treatment; NNT = 5.10].

DISCUSSION

MBCT as a public mental health intervention for adults with mild to moderate depressive symptoms seems effective and applicable in a natural setting.

TRIAL REGISTRATION

Nederlands Trial Register NTR2096.

Mindfulness-based cognitive therapy versus psychoeducational intervention in bipolar outpatients with sub-threshold depressive symptoms: a randomized controlled trial

BACKGROUND

The presence of depressive subsyndromal symptoms (SS) in bipolar disorder (BD) increases the risk of affective relapse and worsens social, cognitive functioning, and quality of life. Nonetheless, there are limited data on how to optimize the treatment of subthreshold depressive symptoms in BD. Mindfulness-Based Cognitive Therapy (MBCT) is a psychotherapeutic intervention that has been shown effective in unipolar depression. The assessment of its clinical effectiveness and its impact on biomarkers in bipolar disorder patients with subsyndromal depressive symptoms and psychopharmacological treatment is needed.

METHODS/DESIGN

A randomized, multicenter, prospective, versus active comparator, evaluator-blinded clinical trial is proposed. Patients with BD and subclinical or mild depressive symptoms will be randomly allocated to: 1) MBCT added to psychopharmacological treatment; 2) a brief structured group psychoeducational intervention added to psychopharmacological treatment; 3) standard clinical management, including psychopharmacological treatment. Assessments will be conducted at screening, baseline, post-intervention (8 weeks) and 4 month follow-up post-intervention. The aim is to compare MBCT intervention versus a brief structured group psychoeducation. Our hypothesis is that MBCT will be more effective in reducing the subsyndromal depressive symptoms and will improve cognitive performance to a higher degree than the psychoeducational treatment. It is also hypothesized that a significant increase of BDNF levels will be found after the MBCT intervention.

DISCUSSION

This is the first randomized controlled trial to evaluate the effects of MBCT compared to an active control group on depressive subthreshold depressive symptoms in patients with bipolar disorder.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02133170. Registered 04/30/2014.

Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review

A fair amount of research exists on acceptance and commitment therapy (ACT) as a model and a treatment for anxiety disorders and OCD spectrum disorders; this paper offers a quantitative account of this research. A meta-analysis is presented examining the relationship between psychological flexibility, measured by versions of the Acceptance and Action Questionnaire (AAQ and AAQ-II) and measures of anxiety. Meta-analytic results showed positive and significant relationships between the AAQ and general measures of anxiety as well as disorder specific measures. Additionally, all outcome data to date on ACT for anxiety and OCD spectrum disorders are reviewed, as are data on mediation and moderation within ACT. Preliminary meta-analytic results show that ACT is equally effective as manualized treatments such as cognitive behavioral therapy. Future directions and limitations of the research are discussed.

The impact of cognitive restructuring and mindfulness strategies on postevent processing and affect in social anxiety disorder

Postevent processing (PEP; reviewing a past social event in detail) is a key maintenance factor of social anxiety disorder (SAD). The current study examined the efficacy of a single session cognitive restructuring or mindfulness strategy on decreasing PEP and its associated effects, and investigated the cognitive processes involved. Fifty-six individuals with SAD completed a speech task to elicit PEP and were taught a cognitive restructuring, mindfulness, or control strategy to manage their negative thoughts. Participants in the cognitive restructuring and mindfulness conditions reported significantly reduced PEP and improved affect as compared to the control condition. There were no significant differences between the cognitive restructuring and mindfulness conditions. Participants in the cognitive restructuring condition reported decreased probability and cost biases. Regardless of study condition, decreases in cost biases and maladaptive beliefs significantly predicted reductions in PEP. Cognitive restructuring and mindfulness appear to be promising strategies to decrease PEP and improve affect.

[Review of the effects of mindfulness meditation on mental and physical health and its mechanisms of action]

Interventions based on mindfulness have become increasingly popular. This article reviews the empirical literature on its effects on mental and physical health, discusses presumed mechanisms of action as well as its proposed neurobiological underpinning. Mindfulness is associated with increased well-being as well as reduced cognitive reactivity and behavioral avoidance. It seems to contribute to enhance immune functions, diminish inflammation, diminish the reactivity of the autonomic nervous system, increase telomerase activity, lead to higher levels of plasmatic melatonin and serotonin. It enhances the quality of life for patients suffering from chronic pain, fibromylagia and HIV infection. It facilitates adaptation to the diagnosis of cancer and diabetes. It seems to lead to symptomatic improvement in irritable bowel syndrome, chronic fatigue syndrome, hot flashes, insomnia, stress related hyperphagia. It diminishes craving in substance abuse. The proposed mechanism of action are enhanced metacognitive conscience, interoceptive exposure, experiential acceptance, self-management, attention control, memory, relaxation. Six mechanism of actions for which neurological underpinnings have been published are: attention regulation (anterior cingulate cortex), body awareness (insula, temporoparietal junction), emotion regulation (modulation of the amygdala by the lateral prefrontal cortex), cognitive re-evaluation (activation of the dorsal medial prefrontal cortex or diminished activity in prefrontal regions), exposure/extinction/reconsolidation (ventromedial prefrontal cortex, hippocampus, amygdala) and flexible self-concept (prefrontal median cortex, posterior cingulated cortex, insula, temporoparietal junction). The neurobiological effects of meditation are described. These are: (1) the deactivation of the default mode network that generates spontaneous thoughts, contributes to the maintenance of the autobiographical self and is associated with anxiety and depression; (2) the anterior cingulate cortex that underpins attention functions; (3) the anterior insula associated with the perception of visceral sensation, the detection of heartbeat and respiratory rate, and the affective response to pain; (4) the posterior cingulate cortex which helps to understand the context from which a stimulus emerges; (5) the temporoparietal junction which assumes a central role in empathy and compassion; (6) the amygdala implicated in fear responses. The article ends with a short review of the empirical basis supporting the efficacy for mindfulness based intervention and suggested directions for future research.

The Relation Between Moment-to-Moment Mindful Attention and Anxiety Among Young Adults in Substance Use Treatment

BACKGROUND

A growing body of research has examined the intersection of mindfulness and substance use, and a large body of research has examined the relation between mindfulness and anxiety. Unfortunately, no research has been conducted on the relation between mindfulness and anxiety symptoms among young adults (i.e., 18-25 years old) in treatment for substance use. The purpose of the current study was to examine the relation between one facet of mindfulness, moment-to-moment attention, and anxiety (panic and generalized anxiety) among young adults in treatment for substance use.

METHODS

Preexisting patient records from a residential substance use treatment center for young adults were reviewed (N = 148). Patient records were examined from May 2012 to August 2013, which represented all young adult patients admitted to the residential treatment facility during this time.

RESULTS

Findings demonstrated that moment-to-moment mindful attention was associated with symptoms of panic disorder and generalized anxiety disorder even after controlling for gender, age, education, alcohol use, drug use, and the shared variance in generalized and panic symptoms. There were no gender differences in moment-to-moment mindful attention.

CONCLUSIONS

These findings provide preliminary evidence that moment-to-moment mindful attention is associated with panic and generalized anxiety in young adults in substance use treatment. Combined with previous research on mindfulness-based interventions among adults in substance use treatment, research should examine the efficacy of mindfulness-based interventions for young adults in substance use treatment.

Mindfulness Meditation to Promote Wellness and Manage Chronic Disease

Lifestyle medicine is a patient-engaged field that has grown in tandem with our increasing knowledge of the importance of lifestyle factors and modifiable health behaviors for disease prevention, health promotion, and the management of chronic illness. Stress is at the epicenter of many negative behaviors that contribute to unhealthy lives, such as smoking, overeating, and unhealthy diets, and lack of activity. Mindfulness meditation is a stress reduction practice that teaches awareness, appreciation, and nonjudgmental acceptance of one’s present experience, thereby short-circuiting reactive, automatic stress reactions. Our systematic review and meta-analysis focuses on the application of randomized controlled mindfulness intervention studies across a broad range of populations and conditions that are relevant to lifestyle medicine. In addition to organizing and highlighting mindfulness research studies that are relevant to the field of lifestyle medicine, we also empirically examine the impact of study design issues (eg, use of different controls, intervention length and duration, sample size, primary outcomes) on the magnitude of effect of mindfulness interventions in lifestyle medicine. Overall, this systematic review and meta-analysis found partial evidence for mindfulness-based interventions to provide short-term benefits across a wide range of lifestyle medicine–relevant populations and study outcomes, particularly focusing on the areas of diet and weight management and symptom burden. Numerous outcome measures were used; however, the most common were the Perceived Stress Scale and the State Trait Anxiety Inventory. This analysis also provides evidence for mindfulness-based interventions that have fewer than 20 individuals per group, as well as partial support for interventions that are less than the standard 8 weeks in duration.

Mindfulness-based cognitive therapy with older adults: an exploratory study

An 8-week mindfulness-based cognitive therapy (MBCT) group for older adults with depression and/or anxiety is described. This article is based on an exploratory study of this therapeutic approach and changes in participants' symptoms associated with participation. Pre-post data from 5 MBCT groups showed significant improvements in reported anxiety, ruminative thoughts, and sleep problems and a reduction in depressive symptoms. Case examples are presented to illustrate these symptom changes. Findings showed that this nonpharmacological intervention is acceptable to older adults and is associated with positive changes. Suggestions are provided for both practitioners and researchers interested in using MBCT with older adults.

Predictor and Moderator Effects of Ego Resilience and Mindfulness on the Relationship Between Academic Stress and Psychological Well-Being in a Sample of Ghanaian College Students

This study examined the predictor and moderator effects of ego resilience and mindfulness on the relationship between academic stress and psychological well-being in a sample of Ghanaian college students ( N = 431). The results indicated that academic stress was positively associated with both anxiety and depression and that mindfulness and ego resilience were both negatively associated with anxiety and depression. Mindfulness buffered the positive relationship between academic stress and depression but not anxiety. In contrast, ego resilience buffered the positive relationship between academic stress and anxiety but not depression. Implications for the study’s findings are discussed and recommendations for future research are presented.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: a meta-analysis of randomised controlled trials

Objective

Mindfulness-based interventions (MBIs) can reduce risk of depressive relapse for people with a history of recurrent depression who are currently well. However, the cognitive, affective and motivational features of depression and anxiety might render MBIs ineffective for people experiencing current symptoms. This paper presents a meta-analysis of randomised controlled trials (RCTs) of MBIs where participants met diagnostic criteria for a current episode of an anxiety or depressive disorder.

Method

Post-intervention between-group Hedges g effect sizes were calculated using a random effects model. Moderator analyses of primary diagnosis, intervention type and control condition were conducted and publication bias was assessed.

Results

Twelve studies met inclusion criteria (n = 578). There were significant post-intervention between-group benefits of MBIs relative to control conditions on primary symptom severity (Hedges g = −0.59, 95% CI = −0.12 to −1.06). Effects were demonstrated for depressive symptom severity (Hedges g = −0.73, 95% CI = −0.09 to −1.36), but not for anxiety symptom severity (Hedges g = −0.55, 95% CI = 0.09 to −1.18), for RCTs with an inactive control (Hedges g = −1.03, 95% CI = −0.40 to −1.66), but not where there was an active control (Hedges g = 0.03, 95% CI = 0.54 to −0.48) and effects were found for MBCT (Hedges g = −0.39, 95% CI = −0.15 to −0.63) but not for MBSR (Hedges g = −0.75, 95% CI = 0.31 to −1.81).

Conclusions

This is the first meta-analysis of RCTs of MBIs where all studies included only participants who were diagnosed with a current episode of a depressive or anxiety disorder. Effects of MBIs on primary symptom severity were found for people with a current depressive disorder and it is recommended that MBIs might be considered as an intervention for this population.

Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners

Numerous studies have begun to address how the brain's gray and white matter may be shaped by meditation. This research is yet to be integrated, however, and two fundamental questions remain: Is meditation associated with altered brain structure? If so, what is the magnitude of these differences? To address these questions, we reviewed and meta-analyzed 123 brain morphology differences from 21 neuroimaging studies examining ∼300 meditation practitioners. Anatomical likelihood estimation (ALE) meta-analysis found eight brain regions consistently altered in meditators, including areas key to meta-awareness (frontopolar cortex/BA 10), exteroceptive and interoceptive body awareness (sensory cortices and insula), memory consolidation and reconsolidation (hippocampus), self and emotion regulation (anterior and mid cingulate; orbitofrontal cortex), and intra- and interhemispheric communication (superior longitudinal fasciculus; corpus callosum). Effect size meta-analysis (calculating 132 effect sizes from 16 studies) suggests a global 'medium' effect size (Cohen's d¯=0.46; r¯=.19). Publication bias and methodological limitations are strong concerns, however. Further research using rigorous methods is required to definitively link meditation practice to altered brain morphology.

PTSD symptoms and pain in Canadian military veterans: the mediating roles of anxiety, depression, and alcohol use

Symptoms of posttraumatic stress disorder (PTSD) and pain are often comorbid among veterans. The purpose of this study was to investigate to what extent symptoms of anxiety, depression, and alcohol use mediated the relationship between PTSD symptoms and pain among 113 treated male Canadian veterans. Measures of PTSD, pain, anxiety symptoms, depression symptoms, and alcohol use were collected as part of the initial assessment. The bootstrapped resampling analyses were consistent with the hypothesis of mediation for anxiety and depression, but not alcohol use. The confidence intervals did not include zero and the indirect effect of PTSD on pain through anxiety was .04, CI [.03, .07]. The indirect effect of PTSD on pain through depression was .04, CI [.02, .07]. These findings suggest that PTSD and pain symptoms among veterans may be related through the underlying symptoms of anxiety and depression, thus emphasizing the importance of targeting anxiety and depression symptoms when treating comorbid PTSD and pain patients.

Internet-based mindfulness treatment for anxiety disorders: a randomized controlled trial

Mindfulness-based interventions have proven effective for the transdiagnostic treatment of heterogeneous anxiety disorders. So far, no study has investigated the potential of mindfulness-based treatments when delivered remotely via the Internet. The current trial aims at evaluating the efficacy of a stand-alone, unguided, Internet-based mindfulness treatment program for anxiety. Ninety-one participants diagnosed with social anxiety disorder, generalized anxiety disorder, panic disorder, or anxiety disorder not otherwise specified were randomly assigned to a mindfulness treatment group (MTG) or to an online discussion forum control group (CG). Mindfulness treatment consisted of 96 audio files with instructions for various mindfulness meditation exercises. Primary and secondary outcome measures were assessed at pre-, posttreatment, and at 6-months follow-up. Participants of the MTG showed a larger decrease of symptoms of anxiety, depression, and insomnia from pre- to postassessment than participants of the CG (Cohen's d(between)=0.36-0.99). Within effect sizes were large in the MTG (d=0.82-1.58) and small to moderate in the CG (d=0.45-0.76). In contrast to participants of the CG, participants of the MTG also achieved a moderate improvement in their quality of life. The study provided encouraging results for an Internet-based mindfulness protocol in the treatment of primary anxiety disorders. Future replications of these results will show whether Web-based mindfulness meditation can constitute a valid alternative to existing, evidence-based cognitive-behavioural Internet treatments. The trial was registered at ClinicalTrials.gov (NCT01577290).

Development and preliminary evaluation of a telephone-based mindfulness training intervention for survivors of critical illness

RATIONALE

Persistent symptoms of psychological distress represent an unmet need among intensive care unit (ICU) survivors.

OBJECTIVES

We aimed to develop and pilot test a simple telephone-based mindfulness training intervention to address this population's unique needs.

METHODS

Open trial involving survivors of medical and surgical critical illness and their informal caregivers, using a pretest-posttest design.

MEASUREMENTS AND MAIN RESULTS

We developed a six-session, telephone-delivered, ICU survivor-specific mindfulness intervention based on past focus groups, the medical literature, and the precedent of the most effective components of existing mindfulness programs. A total of 11 survivors of mechanical ventilation were enrolled, together with 2 informal caregivers for exploratory purposes. Three patients dropped out before intervention initiation because of progressive illness or severe social stressors. Of the 10 remaining participants, 8 (80%) completed the program within 7 weeks. Among these eight patients and caregivers who completed all study procedures, six (75%) experienced improvement in symptoms of psychological distress (anxiety, depression, or post-traumatic stress disorder). Changes in distress symptoms were correlated with improvement in mindfulness qualities, adaptive coping, and emotion regulation. Participants reported high satisfaction with the program in postintervention interviews.

CONCLUSIONS

A new ICU survivor-specific mindfulness training intervention delivered by telephone was acceptable and feasible. Changes in symptoms of distress were correlated with changes in skills that were targeted by the mindfulness program. Controlled trials are needed to further evaluate this promising intervention.

Can mindfulness and acceptance be learnt by self-help?: a systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions

There is growing evidence that mindfulness and acceptance-based interventions have positive consequences for psychological and physical health. The most well-established of these interventions typically involve relatively large resource commitments, in terms of both the provider and participant. A number of recent studies have begun to explore whether the benefits of such interventions can be generalised to less intensive methods. Methods include pure and guided self-help utilising resources such as books and workbooks, computer programmes and applications and audio-visual materials. This paper presents a systematic review and meta-analysis of studies that have evaluated the effectiveness and acceptability of low-intensity interventions including mindfulness and acceptance-based components. Fifteen RCTs (7 ACT-based, 4 mindfulness-based and 4 multi-component interventions including elements of mindfulness and/or acceptance) were identified and reviewed. Interventions that included mindfulness and/or acceptance-based components produced significant benefits in comparison to control conditions on measures of mindfulness/acceptance, depression and anxiety with small to medium effect sizes. Engagement with the self-help interventions varied but on average two-thirds of participants completed post-intervention measures. Emerging research into low-intensity mindfulness and acceptance-based interventions is hopeful. Recommendations for research and practice are presented.

Emotion Regulation: Concepts & Practice in Autism Spectrum Disorder

The purpose of this article is to describe emotion regulation, and how emotion regulation may be compromised in patients with autism spectrum disorder (ASD). This information may be useful for clinicians working with children with ASD who exhibit behavioral problems. Suggestions for practice are provided.

Achtsamkeitsbasierte kognitive Therapie

Unter den im Zentrum dieses Sonderhefts stehenden Neuentwicklungen nehmen achtsamkeitsbasierte Verfahren eine bedeutsame Rolle ein: Während die „Achtsamkeitsbasierte Stressreduktion” (mindfulness-based stress reduction, MBSR) bereits in der zweiten Hälfte der 1970er Jahre entwickelt wurde ( Kabat-Zinn, 1990 ), erlangte insbesondere die von Segal, Williams und Teasdale (2002) speziell für die Rückfallprävention bei rezidivierender depressiver Störung entwickelte „Achtsamkeitsbasierte Kognitive Therapie” (mindfulness-based cognitive therapy, MBCT) eine zunehmende Bedeutung im Bereich kognitiv-behavioraler Ansätze. Der vorliegende Beitrag geht zunächst auf den historischen und theoretischen Hintergrund der Achtsamkeitsbasierten Kognitiven Therapie ein. Im Anschluss daran wird die praktische Umsetzung des Gruppenkonzepts vorgestellt und der Stand der Forschung anhand aktueller Metaanalysen referiert. Der Beitrag schließt mit einer kritischen Diskussion einer allzu verkürzten Anwendung von Achtsamkeit in der klinischen Praxis.

A randomised controlled trial of a brief online mindfulness-based intervention

OBJECTIVES

There is growing evidence that mindfulness has positive consequences for both psychological and physical health in both clinical and non-clinical populations. The potential benefits of mindfulness underpin a range of therapeutic intervention approaches designed to increase mindfulness in both clinical and community contexts. Self-guided mindfulness-based interventions may be a way to increase access to the benefits of mindfulness. This study explored whether a brief, online, mindfulness-based intervention can increase mindfulness and reduce perceived stress and anxiety/depression symptoms within a student population.

METHOD

One hundred and four students were randomly allocated to either immediately start a two-week, self-guided, online, mindfulness-based intervention or a wait-list control. Measures of mindfulness, perceived stress and anxiety/depression were administered before and after the intervention period.

RESULTS

Intention to treat analysis identified significant group by time interactions for mindfulness skills, perceived stress and anxiety/depression symptoms. Participation in the intervention was associated with significant improvements in all measured domains, where no significant changes on these measures were found for the control group.

CONCLUSIONS

This provides evidence in support of the feasibility and effectiveness of shorter self-guided mindfulness-based interventions. The limitations and implications of this study for clinical practice are discussed.

Overview of systematic reviews: yoga as a therapeutic intervention for adults with acute and chronic health conditions

Objectives. Overview the quality, direction, and characteristics of yoga interventions for treatment of acute and chronic health conditions in adult populations. Methods. We searched for systematic reviews in 10 online databases, bibliographic references, and hand-searches in yoga-related journals. Included reviews satisfy Oxman criteria and specify yoga as a primary intervention in one or more randomized controlled trials for treatment in adults. The AMSTAR tool and GRADE approach evaluated the methodological quality of reviews and quality of evidence. Results. We identified 2202 titles, of which 41 full-text articles were assessed for eligibility and 26 systematic reviews satisfied inclusion criteria. Thirteen systematic reviews include quantitative data and six papers include meta-analysis. The quality of evidence is generally low. Sixteen different types of health conditions are included. Eleven reviews show tendency towards positive effects of yoga intervention, 15 reviews report unclear results, and no, reviews report adverse effects of yoga. Yoga appears most effective for reducing symptoms in anxiety, depression, and pain. Conclusion. Although the quality of systematic reviews is high, the quality of supporting evidence is low. Significant heterogeneity and variability in reporting interventions by type of yoga, settings, and population characteristics limit the generalizability of results.

The breathing conundrum-interoceptive sensitivity and anxiety

Cognitive and affective processing has been the central focus of brain-related functions in psychology and psychiatry for many years. Much less attention has been paid to what could be considered the primary function of the brain, to regulate the function of the body. Recent developments, which include the conceptualization of interoception as a process consisting of integrating the information coming from the inside of the body in the central nervous system and the appreciation that complex emotional processes are fundamentally affected by the processing and regulation of somatic states, have profoundly changed the view of the function and dysfunction of the brain. This review focuses on the relationship between breathing and anxiety. Several anxiety disorders have been associated with altered breathing, perception of breathing, and response to manipulations of breathing. Both clinical and experimental research studies are reviewed that relate breathing dysfunctions to anxiety. Altered breathing may be useful as a physiological marker of anxiety as well as a treatment target using interoceptive interventions.