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Well-Being, Mental Health, General Health and Quality of Life Improvement Through Mindfulness-Based Interventions: A Systematic Review and Meta-Analysis

AUTHORS

Elham Aghaie 1 , Rasol Roshan 1 , * , Parvaneh Mohamadkhani 2 , Mohamadreza Shaeeri 1 , Mohamad Gholami-Fesharaki 3

1 Department of Clinical Psychology, Faculty of Humanistic Sciences, Shahed University, Tehran, IR Iran

2 Department of Clinical Psychology, Faculty of Clinical Psychology, University of Social Walfare and Rehabilitation Sciences, Terhran, IR Iran

3 Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran

How to Cite: Aghaie E, Roshan R, Mohamadkhani P, Shaeeri M, Gholami-Fesharaki M. Well-Being, Mental Health, General Health and Quality of Life Improvement Through Mindfulness-Based Interventions: A Systematic Review and Meta-Analysis, Iran Red Crescent Med J. 2018 ; 20(3):e16231. doi: 10.5812/ircmj.16231.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 20 (3); e16231
Published Online: February 24, 2018
Article Type: Systematic Review
Received: July 3, 2017
Revised: November 28, 2017
Accepted: February 7, 2018
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Abstract

Context: Mindfulness-based interventions have shown promising therapeutic outcomes in improving well-being, mental health, general health, and quality of life; however, findings in this regard are inconsistent. The present study aimed at clarifying this inconsistency in the literature focusing on the Iranian studies through a systematic review and meta-analysis study.

Evidence Acquisition: The databases of Pubmed, Scopus, Doaj, EBSCO, Iranmedex, MagIran, SID, and Comprehensive Human Sciences Portal, and additional resources were searched using the set terms of “mindfulness” OR “mindfulness-based cognitive therapy” OR “MBCT” OR “mindfulness-based stress reduction” OR “MBSR” AND “intervention” AND “well-being” OR “health” OR “quality of life” and the time limit of the records was set between March 2008 and May 2017. The language of the search was restricted to English and Farsi. The studies that conducted on Iranian populations were selected in this review, only. Thirty-five studies conducted on 3013 subjects were assessed. Cochrane Q-test and I-squared index were used to detect the heterogeneity among results, and fixed effect model with a 95% Confidence Interval (CI) was applied. The effect size of mindfulness-based interventions on well-being, mental health, general health, and quality of life improvement, measured by Hedge`s g ratios, were respectively 1.54, 1.08, 0.89, and 1.87. Results: The findings showed that the effect size of mindfulness-based interventions on well-being, mental health, general health, and quality of life improvement were of high magnitude, according to the Cohen’s table.

Conclusion: Mindfulness-based interventions effectively improved well-being, health, and quality of life.

Keywords

Mental Health Meta-Analysis Mindfulness Quality of Life

Copyright © 2018, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Introduction

During the last decades, psychologists have largely ignored well-being and quality of life, and instead their main focus has been on mental disorders and issues, such as depression and anxiety (1). In 1998, Seligman et al. introduced positive psychology, as a new domain in psychology. This approach expanded the focus of clinical psychology beyond merely manifestation and treatment of unpleasant symptoms of a disorder. Under this approach, psychotherapy not only aims at improving the symptoms of a disorder, but also tries to improve the well-being of individuals (2, 3).

Mindfulness is one of the treatments of positive psychology proposed by Kabat-Zinn (4). Mindfulness-based interventions have shown promising therapeutic outcomes for several psychological and physical disorders, such as chronic pain, depression, postpartum depression, anxiety, and addictions (5-20). This intervention aims at alleviating pathogenic agents, while also emphasizing on the capacities of mindfulness-based interventions to optimize psychological and behavioral functioning. This treatment is conceptualized as improving well-being and has become popular among scientists during the past decade (21). Apparently, as mindfulness components are improved, well-being is promoted (22, 23). However, results of previous researches are contradictory. The findings of a meta-analysis conducted by Sin et al. (24), Khoury et al. (25) and Chiesa et al. (26) presented a moderate effect size for MBCT and MBSR. In a systematic review and meta-analysis by Goyal et al. (27) weak evidence was indicated regarding the effects of mindfulness meditation approaches on positive mood and quality of life-related mental health. The results of another meta-analysis conducted by Spijkerman et al. (28) demonstrated that online mindfulness-based interventions had a slight influence on well-being (g = 0.23). Also, Eberth and Sedlmeier (19) performed a meta-analysis on 38 studies that had evaluated the effects of mindfulness meditation on psychological well-being. They concluded that MBSR had the greatest effect on attaining higher psychological well-being.

In addition, several studies have been conducted on the effects of mindfulness on well-being, mental health, general health, and quality of life improvement in Iran. However, there is no comprehensive systematic review conducted on the findings of existing studies from Iran. Therefore, the present study aimed at performing a systematic review of studies conducted on the effects of mindfulness-based interventions on well-being, mental health, general health, and quality of life improvement through a systematic review and meta-analysis study. The main focus of this study was reviewing researches conducted on Iranian samples.

2. Evidence Acquisition

2.1. Data Source and Search Strategy

Scientific records were retrieved by a systematic search of several bibliographic databases and the last search was updated on October 30th, 2017. The databases of PubMed, Scopus, DOAJ, EBSCO, Iranmedex, MagIran, Scientific Information Database SID, Comprehensive Human Sciences Portal, and additional resources were searched using set terms of (“mindfulness” OR “mindfulness training” OR “mindfulness-based cognitive therapy” OR “MBCT” OR “mindfulness-based stress reduction” OR “MBSR” OR “mindfulness-based relapse prevention” OR “MBRP”) AND “intervention” AND (“well-being” OR “general health” OR “mental health” OR “quality of life”). The time limit of the records was set as March 2008 to May 2017. The language of search was restricted to English and Farsi. Only studies conducted on Iranian populations were selected in this study. The titles and abstracts of all the retrieved records, identified by the search strategy, were carefully reviewed by 2 authors and the relevant records with full texts available were selected for further assessments. The reference lists of the selected records were also checked manually to identify additional eligible studies to be included in the full analysis. Furthermore, to find existing grey literature, an extra search was performed on Google. After finding related titles, the references of all of the included studies were explored to identify additional studies.

The PRISMA Flowchart of the Study Design Process
Figure 1. The PRISMA Flowchart of the Study Design Process
Effects of Mindfulness-Based Interventions on Well-Being, Mental Health, General Health and Quality of Life
Figure 2. Effects of Mindfulness-Based Interventions on Well-Being, Mental Health, General Health and Quality of Life
Funnel Plot of the Effects of Mindfulness-Based Interventions on Well-Being, Mental Health, General Health and Quality of Life
Figure 3. Funnel Plot of the Effects of Mindfulness-Based Interventions on Well-Being, Mental Health, General Health and Quality of Life

2.2. Study Selection

According to the inclusion criteria, 3013 articles were selected. Overall, 2854 articles were excluded due to duplication and no access to full- texts, and 159 remained in the next step, 96 of which were then excluded due to lack of relevance (non-Iranian population, abstract available only, presented at conferences and seminars, letter to editors and case report) and 63 remained. Furthermore, 30 articles were excluded due to quality assessment through the full text. Two papers were added from references. Finally, according to the exclusion criteria, 35 papers remained in the study.

2.3. Inclusion and Exclusion Criteria

According to the PRISMA guidelines for reporting a systematic review, the selection and screening of studies for inclusion or exclusion were performed independently by two authors, at the end of each level of screening and disagreements between the authors were resolved by mutual discussions. The Kappa coefficient was 75%.

In this study, only original articles were eligible if they evaluated the effectiveness of any type of mindfulness-based interventions (MBCT, MBSR, etc.) regarding the improvement of well-being, general health, mental health, and quality of life in clinical or non-clinical populations (Table 1)

Exclusion criteria: 1) duplicated studies, 2) non-original studies, 3) studies with non-Iranian samples, 4) studies that did not report a specific sample size, and 5) studies without an experimental research group.

2.4. Data Extraction

In this study, researchers independently evaluated all studies derived from the above databases and then compared their results. The required data (author’s last name, study title, publication year, study settings, dependent variable, tools, treatments, and sample size) with corresponding 95% confidence intervals were extracted from all documents.

2.5. Quality Assessment

Cochran’s risk of bias assessment tool was used for quality assessment of each included paper (29) and the following bias risks were evaluated: Random sequence generation (selection bias), allocation concealment (selection bias), accurate measurement independent variable (performance bias), incomplete outcome data, missing data or loss during the intervention (attrition bias), selective reporting (reporting bias), timing of outcome assessments, and other biases. Each bias risk for each paper was rated as high, moderate, and low. High and moderate risks were scored as zero and low risk as one. Articles with a score of more than 6 were categorized as low risk studies.

2.6. Statistical Analysis

Data analysis was performed using the Comprehensive Meta-Analysis Software (CMA version 2.0). The heterogeneity test was performed using Cochran’s Q test and I-Squared (ranges from 0% to 100%). According to the result of the heterogeneity test (Table 1), the fixed-effect model was used for determining Hedge’s g in the studies.

Sensitivity analysis was conducted to assess the sensitivity of each study by sequential omission of each study. Publication bias was checked by funnel plots (Figure 3).

3. Results

A total of 3013 papers were identified in the databases. After removing duplications and irrelevant articles, 159 papers remained for screening. The characteristics of studies are presented in Table 1. At each level of screening, 35 full-text articles remained for the meta-analysis (Figure 1). Based on the heterogeneity indices for well-being (I-Squared = 0%, Q = 4.94, and P value = 0.4) and the low observed heterogeneity, the effectiveness of mindfulness-based intervention on well-being, by using a fixed model, was estimated as 1.54 (95% CI: 1.24 to 1.85). Based on the heterogeneity indices for general health (I-Squared = 10.59%, Q = 5.59 and P value = 0.3) and the low observed heterogeneity, the effectiveness of mindfulness-based intervention for general health by using fixed model was estimated as 0.89 (95% CI: 0.62 to 1.17).

Based on the heterogeneity indices for mental health (I-Squared = 19.38%, Q = 7.44, and P value = 0.2) and the low observed heterogeneity, the effectiveness of mindfulness-based intervention for mental health by using a fixed model was estimated as 1.082 (95% CI: 0.80 to 1.36).

Based on the heterogeneity indices for quality of life (I-Squared = 0%, Q = 11.07, and P value = 0.7) and the low observed heterogeneity, the effectiveness of mindfulness-based intervention on general health by using a fixed model was estimated as 1.187 (95% CI: 0.999 to 1.37).

To assess publication biases, a funnel plot was used (Figure 3).

Table 1. Characteristics of Studies for Efficacy of Mindfulness-Based Interventions on Well-Being
SubjectsGenderAge, yearNumber of SessionTreatmentToolSamplesDependent VariableStudy
Thirty diabetic patientsMale42 - 598MBSRSF - 36N = 40Quality of lifeArefnasab, Z (30)
Patients with breast cancerFemale30 - 558MBSRQLQ - 30N = 24Quality of lifeRahmani (31)
Patients with chronic low back painFemale30 - 458MBSRSF - 12N = 88Quality of lifeBanth (32)
Volunteer addictsFemale-10MBCTGHQN = 40General healthKazemian, S (33)
Female studentsFemale20 - 3712Mindfulness behavior therapyWHO - QOL - 26N = 30Quality of lifeZamzami, A (34)
Amputee veteran wivesMale & Female23 - 648MBSRQuality of life (SF - 36)N = 28Quality of lifeZarnaghash, M (35)
Students living in a dormitoryFemale-8MBCTWHO - QOL - brefN = 29Quality of lifeKavyani, H (36)
Patients with chronic low Back PainMale & Female30 - 508MBCRQuality of life (SF - 36)N = 18General healthMasumian, S (37)
Patients with chronic low back painMale & Female30 - 508MBCRQuality of life (SF - 36)N = 18Mental healthMasumian, S (37)
Military personnelMale30 - 508MBCRPsychological well - being(SPWB)N = 30Psychological healthFeizah. A (38)
Patients with type 2 diabetesMale & Female35 - 658MBCTQuality of life (SF - 36)N = 42Quality of lifeGhashghaee, S (39)
Patients with type 2 diabetesMale& Female35 - 658MBCTQuality of life (SF - 36)N = 42Emotional healthGhashghaee, S (39)
Patients with type 2 diabetesMale & Female35 - 658MBCTQuality of life (SF - 36)N = 42General healthGhashghaee, S (39)
Patients with epilepsyMale & Female18 - 458MBCTPsychological well – being (PWB - 18)N = 30Psychological well - beingMohamadpur, S (40)
Thirty diabetic patientsMale & Female-8MBSRDiabetes quality of life questionnaireN = 30Quality of lifeRaghebian (41)
NurseMale/Female20 - 608MBSRSF - 36N = 22Mental healthMirrajaie (42)
NurseMale/Female20 - 608MBSRSF - 36N = 22General healthMirrajaie (42)
Master of ScienceMale/Female30 - 608MBCTQLQ (Quality of Life Questionnaire)N = 30Quality of lifeAskari (43)
Master of ScienceMale/Female30 - 608MBCTQLQN = 30Mental healthAskari (43)
Master of ScienceMale/Female20 - 408MBCTSF - 36N = 30General healthIzadi (44)
Master of ScienceMale/Female20 - 408MBCTSF - 36N = 30Well - beingIzadi (44)
Opium abusersMale-8MBSRSF - 36N = 60General healthImani (45)
Opium abusersMale-8MBSRSF - 36N = 60Well - beingImani (45)
StudentsMale/Female-8MBCTWHO - QOL - BREFN = 34Quality of lifeJafari (46)
People with coronary artery diseaseMale/Female358MBSRSF - 36N = 30Quality of lifeHeshmati (47)
TeachersFemale8Mindfulness trainingRyff - Bref formN = 30Well - beingJenabadi (48)
Master of ScienceFemale20 - 408MBCTSF - 36N = 30Quality of lifeBakhshipur (49)
Irritable bowel syndromeMale/Female18 - 408mindfulness - based therapyIBS - QOL34 scalesN = 24Quality of lifeZomorodi (50)
Women caregivers (members of Alzheimer’s association)Female-8MBCTSF - 36N = 20Quality of lifeNoruzi (51)
War victimsmale35 - 608MBSRWHOQOL - 26N = 28Quality of lifeMarzabadi (52)
War victimsmale35 - 608MBSRWHOQOL - 26N = 28Mental healthMarzabadi (52)
Woman with InfertilityWoman20 - 458MBCTGHQ - 28N = 60Mental healthAbedishargh (53)
HIV patientsmale-8Mindfulness trainingRyff QuestionnaireN = 30Well - beingMirzavand (54)
Women with breast cancerFemale-8MBCTQLQ - 30N = 24Quality of lifePato (55)
Women with insomnia disorderFemale28 - 458MBCTGeneral health QuestionnaireN = 20Mental healthFarahbakhsh (56)
Table 2. Heterogeneity Indicators in Effect Size
GroupQ-ValuedfPI2
G1Well-being4.9450.40.000
G2General health5.5950.310.59
G3Mental health7.4460.219.38
G4Quality of life11.07150.70.000

4. Discussion

A meta-analysis performed by integrating the results of different studies gives a more comprehensive view of variables effect size. One of the best characteristics of a meta-analysis is that it allows comparison between efficiency of different treatment patterns in various cultural contexts.

In this meta-analysis, 35 studies investigating the effects of mindfulness-based interventions on well-being, mental health, general health, and quality of life were examined. The results showed that mindfulness-based interventions significantly influenced well-being, general health, mental health, and quality of life.

Findings of the current study support the findings of the meta-analysis conducted by Sedlmeier and Eberth (19), which reported large effect size, whereas the current findings are inconsistent with the findings of Goyal et al. (27) and Spitkermand and Bohlmeijer (28), who reported a small effect size and with that of Khoury et al. (25), Sin and Lybumrsky (24), Chiesa et al. (26), which reported a moderate effect size.

It should be noted that different populations were studied in the researches included in this meta-analysis. Therefore, it is recommended for studies with similar topics to be replicated so that a better view can be captured by combining and comparing similar samples. These results indicate that mindfulness-based interventions are useful for improving well-being, health, and quality of life in the Iranian population.

Mindfulness interventions are reportedly associated with reduced attention bias, especially in response to negative stimuli (57, 58). However, instability on negative events is not enough to promote well-being. In scientific models of mindfulness, descriptions of factors that lead to positive change and promotion of well-being are limited (59). Therefore, conducting further studies is necessary to shed more light on the mechanisms of action of mindfulness-based interventions in promotion of well-being.

4.1. Conclusion

These results suggest that clinicians can recommend mindfulness programs to their patients and non-patients as a means to improve well-being, mental health, general health, and quality of life.

Acknowledgements

Footnotes

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