Mindfulness meditation for Chinese patients with psychosis: A systematic review and meta-analysis
Introduction
Psychosis is a serious mental illness characterized by significant distortions in perceived reality, with hallucination and delusion being its core symptoms. It often results in devastating impairments in one's physical health and psychosocial functioning (Schoepf et al., 2014). Psychosis has a median lifetime prevalence of 7.49 per 1000 individuals among the general population (Moreno-Küstner et al., 2018). In China alone, around 7.5 million people suffer from psychosis during their lifetime (Long et al., 2014). Globally, the high prevalence also results in an economic impact up to a 1.65% drop in Gross Domestic Product (GDP; Chong et al., 2016).
While antipsychotics have been consistently shown as an effective first-line treatment for acute symptoms (Kishi et al., 2019), its long-term effects remain controversial (Hui et al., 2018; Wunderink et al., 2013). In contrast, psychosocial interventions may offer more promising results for symptomatic remission (Álvarez-Jiménez et al., 2011). Following the first-wave (i.e., behavioral conditioning) and second-wave (i.e., cognitive theories) of cognitive behavioral therapies (CBT), recent decades have witnessed a surge in its third-wave strategies – mindfulness- and acceptance-based interventions (Louise et al., 2018). While mindfulness originated from Buddhist meditation, it has been adapted for contemporary psychology (Kabat-Zinn, 1982; Segal et al., 2002). Mindfulness refers to “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4) and is the backbone of one of its prominent perches – mindfulness meditation (MM). Apart from mindfulness, MM also emphasizes two closely related concepts, acceptance (i.e., an open attitude when facing arousing information) and compassion (i.e., a soothing state involving love and kindness for self and others; Aust and Bradshaw, 2017; Jansen et al., 2020). As the interpretation of MM varies, for the purpose of this review, MM will be operationally defined as a family of interventions, encompassing mindfulness-based (MBIs), acceptance-based (ABIs) and compassion-based interventions (CBIs), in keeping with previous reviews (Aust and Bradshaw, 2017; Cramer et al., 2016; Jansen et al., 2020; Khoury et al., 2013).
While MM was first applied to pain (Kabat-Zinn, 1982) and depression (Segal et al., 2002) management, recent research has witnessed its adapted applications in serious mental illnesses. A few meta-analyses involving patients with psychosis suggested that MBIs and ABIs improve psychotic, depressive and anxiety symptoms, functioning, quality of life (QoL), mindfulness and acceptance levels, as well as rehospitalization-related outcomes (Cramer et al., 2016; Jansen et al., 2020; Khoury et al., 2013; Louise et al., 2018; Sabe et al., 2019; Tonarelli et al., 2016). Khoury et al. (2013) found that mindfulness, acceptance, and compassion combined moderated the effect size of clinical outcomes. Furthermore, long-term effects of MM in improving the overall symptomatology (≥3 months) and rehospitalization duration (≥6 months) have also been found (Cramer et al., 2016; Jansen et al., 2020). However, these findings should be interpreted in view of the heterogeneity across study designs and results responsible for differing effect sizes of MM (Khoury et al., 2013). For example, larger effect sizes were usually observed following MBIs (vs. ABIs; Jansen et al., 2020; Louise et al., 2018) and a group-based (vs. individual-based) delivery format (Jansen et al., 2020; Louise et al., 2018). Meanwhile, inclusion of an active control condition (e.g., psychoeducation; vs. treatment-as-usual) usually weakened the effect (Louise et al., 2018). So far, no moderation effects were found for study quality, treatment setting or duration (Jansen et al., 2020; Louise et al., 2018).
Historically, MM is one of the mind-body interventions long utilized by traditional Chinese medicine practitioners for health promotion (Atkins, 2018). Under the deep-rooted values of collectivism and social harmony in Chinese culture, people with serious mental illnesses tend to demonstrate more self-blame and less self-affirmation (Chien and Thompson, 2014; Lam and Chien, 2016). Furthermore, influenced by the conventional idea of mind-body unity, the Chinese population is more inclined to experience psychiatric conditions somatically rather than mentally (Chan et al., 2015). These culture-specific features signify the Chinese population as a suitable recipient of MM, considering its emphasis on mind-body connections.
Nevertheless, few studies to date have explored the effects of MM on Chinese patients with psychosis. This paper aimed to address this literature gap by systematically reviewing evidence for MM among Chinese patients with psychosis, and to conduct a comprehensive meta-analysis of relevant intervention studies. We attempted to address the following questions: (1) Does MM improve clinical (e.g., psychotic and affective symptoms, insight, medication adherence, recovery-, relapse- or rehospitalization-related outcomes), well-being (e.g., functioning, QoL, coping, self-efficacy, self-esteem, perceived stigma, social support), and third-wave (e.g., mindfulness-related) outcomes in Chinese patients with psychosis? (2) What are the patient- and/or intervention-specific factors that moderate the efficacy of MM? (3) Are improvements on third-wave outcomes associated with improvements on clinical and well-being outcomes? (4) What are the mechanisms underlying the effects of MM?
Section snippets
Eligibility criteria
We included articles that: (1) described an intervention study (e.g., randomized controlled trial [RCT], pre-post tests), where MM was administered in the experimental condition; (2) involved Chinese-speaking patients diagnosed with psychotic disorders according to a well-established diagnostic system1
Study selection
Of the 1053 articles initially retrieved, our eligibility criteria included 23 articles in the qualitative synthesis and 22 in the quantitative synthesis (Fig. 1).
Study characteristics
Key characteristics of the included articles are summarized in Table 1. Twenty-three included articles described 20 studies (18 RCTs and two pre-post tests), from mainland China (16 studies), Hong Kong SAR (3 studies), and Taiwan (1 study), comprising a total of 1749 patients. Fifteen of the 20 studies included schizophrenia patients,
Discussion
This is the first systematic review and meta-analysis to investigate the efficacy of MM in Chinese patients with psychosis, including 23 English and Chinese articles with 1749 patients. MM was found to improve patients' mindfulness level and such improvement was associated with enhancements in clinical and wellbeing outcomes. While it remains questionable whether MM enhances outcomes in one aspect triggering improvements in the others, or that it induces an effect on multiple outcomes
Conclusion
Our systematic review and meta-analysis supports the efficacy of MM for Chinese patients with psychosis. Future trials should specify the homework requirements for participants as well as the training and qualifications received by MM instructors, as these could moderate the efficacy of MM. Follow-up assessments should also be integrated to indicate the sustainability of the intervention effects. As mentioned, there is currently a paucity of research into the underlying mechanisms of MM,
Role of the funding source
This work was supported by the General Research Fund of The Research Grants Council of Hong Kong (Ref: 17110918). The funding body had no involvement in any aspect of the manuscript preparation.
CRediT authorship contribution statement
All authors have actively participated in this manuscript. Authors T.J.T. and C.L.M.H. contributed to the conception of the review. T.J.T. performed the literature search. T.J.T. and C.L.M.H. screened articles for eligibility and extracted data from eligible studies. T.J.T. conducted the analyses while C.L.M.H. verified the methodology. T.J.T. wrote the first draft of the manuscript. C.L.M.H. and B.S.T.L. proofread and fine-tuned the manuscript. All authors provided critical review and approved
Declaration of competing interest
Author E.Y.H.C. has received speaker honoraria from Otsuka and DSK BioPharma; received research funding from Otsuka; participated in paid advisory boards for Jansen and DSK BioPharma; received funding to attend conferences from Otsuka and DSK BioPharma. Other authors declare no competing interests. The authors alone are responsible for the content and writing of the paper.
Acknowledgment
We would like to thank all of the researchers who kindly provided us with the data necessary to complete this meta-analysis.
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