Meditation-based mind-body therapies for negative symptoms of schizophrenia: Systematic review of randomized controlled trials and meta-analysis
Introduction
Yoga, tai-chi, qi-gong, and mindfulness are different mind-body therapies used to promote general health and to reduce stress. These various forms of meditation practice share commons roots and are suggested to have comparable effects on mind and body, in particular with a small to moderate reduction in multiple negative dimensions of psychological stress (Goyal et al., 2014). In this systematic review we focus on techniques that include meditation as an essential component and do not address other mind-body interventions or psychotherapies. Yoga, tai-chi, qi-gong, and mindfulness include meditation for beginners that consists of basic training of internal concentration by focusing the body and/or breathing, and leads to an altered dynamic of consciousness. Meditation practice is essentially a practice of awareness and all the considered interventions share fundamental meditation exercises such as sited meditation or body-scans (Brown et al., 2015).
Over the last decade researchers have suggested that these group practices could have a therapeutic role for patients suffering from schizophrenia as add-on therapy to antipsychotic treatment (Behere et al., 2011; Helgason and Sarris, 2013; Louise et al., 2018; Vancampfort et al., 2012). Broderick and Vancampfort have provided a series of Cochrane reviews on yoga for schizophrenia (Broderick et al., 2015; Broderick and Vancampfort, 2019). They applied strict inclusion criteria and could only identify a very limited number of small studies that lacked many key outcomes, which precluded concluding on the efficacy of yoga interventions.
In this context the negative symptoms of schizophrenia are a therapeutic target of high interest, as effective treatment remains an unmet therapeutic challenge (Aleman et al., 2017). Several mechanisms of meditation-based mind-body therapies could potentially contribute to an amelioration of negative symptoms. First, empowerment of self-control over symptoms is a common mechanism of these therapies and could support a modification of defeatist beliefs associated with negative symptoms (Campellone et al., 2016). Second, meditation has been suggested to stimulate the reward system, which is dysfunctional in patients with negative symptoms, and to improve anhedonia (Kirk and Montague, 2015).
An interesting recent meta-analysis focusing on the broader effects of exercise on negative symptoms has also addressed mind-body exercise (Vogel et al., 2019). The authors included yoga and tai-chi but not mindfulness interventions, thus focusing on the exercise and not the meditation aspect of practice. They found a positive effect of mind-body exercise on negative symptoms, but it is not clear whether this result applies to all meditation-based practice. In addition, they did not perform subgroup analysis to compare different mind-body interventions.
We conducted a systematic review of all randomized clinical trials (RCTs) investigating the effect of meditation-based mind-body therapies as adjunctive treatment to antipsychotic treatment on negative symptoms. Our primary hypothesis was that practice of meditation-based mind-body therapies would lead to a lower negative symptom severity in comparison to treatment-as-usual or to a non-specific control intervention. We did not perform a comparison with specific interventions that have previously been associated with an improvement of negative symptoms (e.g. exercise, social skills training), because we wanted to detect an efficacy signal and not superiority over another form of specific treatment. Our secondary hypothesis was that addition of mind-body therapies would not lead to an increase in positive symptoms.
It has been suggested that longer mind-body interventions have stronger effects, but this question has so far not been addressed in patients with schizophrenia (Carmody and Baer, 2009; Fjorback et al., 2011). Therefore, we planned to explore if negative symptom severity at endpoint is associated with total hours of practice.
Section snippets
Registration
This work was prepared according to Preferred Reporting items for Systematic reviews and Meta-Analyses (PRISMA-P) guidelines (Moher et al., 2009). On 17th January 2019, the protocol entitled “Mind-body therapies as treatment of negative symptoms of schizophrenia: systematic review of randomized controlled trials and meta-analysis” was published in the International Prospective Register of Systematic Reviews (PROSPERO CRD42019120394); from that date forward it is available from: //www.crd.york.ac.uk/PROSPERO/
Search results
The systematic review searches yielded 1100 unique references. On the basis of their title, 815 articles were excluded for reasons described in flow-chart (Fig. 1). Screening of abstract and trial protocol led to 197 exclusions, leaving 88 articles for full-text article review for eligibility. One study was excluded for insufficient duration of intervention (20 min per sessions, for a total of 4 h of practice) (Ikai et al., 2017). Two studies with a light aerobic exercise group as a control
Effects of mind-body therapies on negative symptoms
To our knowledge this is the first meta-analysis to evaluate the potential therapeutic effect of mind-body therapies on negative symptoms including all meditation-based practices. Overall, we found a small beneficial effect of mind-body interventions on negative symptoms compared to treatment-as-usual or non-specific control interventions in the presence of high heterogeneity. Subgroup analysis allowed to partially account for heterogeneity and showed positive effects of mindfulness and yoga
Conclusions
Our results suggest a potential for meditation-based mind-body therapies in the treatment of negative symptoms, in particular for mindfulness based approaches and to a lesser extent yoga. Across all treatment approaches we did not find any evidence for worsening of positive symptoms. It is important to note that none of the studies did primarily target negative symptoms, nor did they correspond to current recommendations for RCTs targeting negative symptoms. Therefore, it is not possible to
Contributors
MS, OS and SK designed the study and wrote the protocol. MS and SK conducted the literature searches and data collection. MS analyzed the data. MS wrote the first draft of the manuscript. MS, OS, and SK reviewed the final version of the manuscript.
Declaration of competing interest
Stefan Kaiser has received royalties for cognitive test and training software from Schuhfried and advisory board honoraria from Recordati and Lundbeck on an institutional account for research and teaching. Othman Sentissi has received advisory board honoraria from Otsuka, Lilly, Lundbeck, Sandoz, and Janssen on an institutional account for research and teaching. Michel Sabe declares no conflict of interest.
Acknowledgements
We thank Dr. C Combescure (Center for Clinical Research, Geneva University Hospitals) for his very valuable methodological advice.
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