Mindfulness-based online intervention for mental health during times of COVID-19.

Background: As the COVID-19 pandemic progresses, mental health begins to be affected. In this sense, practical and low-cost solutions are necessary to minimize the impact on the population. Aim: This study aimed to determine the effect of a mindfulness-based online intervention for mental health during times of COVID-19. Method: A quasi-experimental study was carried out with pre-test and post-test measurements in a sample of 62 participants divided into an experimental group whose members were administered a 12-session mindfulness online program, and a control group on the waiting list. The Zung Self-Rating Anxiety Scale (SAS) was used to assess anxiety, the Zung Self-Rating Depression Scale (SDS) to measure depression, and the Perceived Stress Scale (PSS-14) to determine stress levels.
Results: The levels of anxiety, depression, and stress decreased after the intervention, finding significant differences between the groups and study phases (P < 0.05). In addition, moderate changes in anxiety (d = 0.849, g = 0.847) and depression (d = 0.533, g = 0.530) were found, as well as important changes in stress reduction (d = 1.254, g = 1.240).
Conclusion: There is evidence of a potential for the use of mindfulness program to reduce stress, anxiety, and depressive symptoms in stressful situations such as the COVID-19 pandemic. Copyright:

INTRODUCTION

At the end of December 2019, in the Chinese city of Wuhan, an epidemic outbreak caused by a new coronavirus (SARS-CoV-2) was reported, the source of the disease called COVID-19, which has spread throughout the world, causing an unprecedented situation and conditioning various aspects of people’s lives.[1] To stop the contagion, governments implemented sanitary measures such as home quarantine, social distancing, travel restrictions, bans on mass gatherings and sports, regular hand washing, use of face masks, teleworking, restaurants, and school closures, among others.[2] All these situations caused unforeseen behavioral changes as paranoid behaviors fear of the contagion, and the added tension of social stressors such as economic crisis, added altogether, may be the cause for growing increase in mental health problems.[3]

An investigation indicated that the prescriptions of anti-anxiety and sleep aid medication in the population increased by 35.7% and 41.2%, respectively, due to the pandemic.[4] Likewise, evidence points that there is a negative impact on mental health among the general population as well as health workers; levels of depression and symptoms related to post-traumatic stress disorder (PTSD) have increased.[5] In this panorama, the term “coronaphobia” was even coined to describe the fear and anxiety caused by the pandemic,[6] associated to high levels of depression, anxiety, hopelessness, suicidal ideation, and functional impairment.[7]

On the other hand, mindfulness is the most widely accepted mind–body therapy of complementary and alternative medicine, as well as it is integrated in 79% of medical schools in the United States, in activities that promote wellness as research.[8] In this sense, numerous studies suggest that mindfulness can reduce levels of anxiety and depression, as well as regulate emotions.[9] Besides, mindfulness-based interventions also perform comparably better than cognitive behavioral therapy, especially for anxiety and depression.[10]

In this sense, the coronavirus pandemic could be a risk factor to people to suffer from a wide range of psychological difficulties, which is the reason to find practical and low-cost alternatives to face these problems. For this, a study was carried out to determine the effectiveness of a mindfulness program for the improvement of mental health in times of COVID-19.

METHODS

Study design and sample

A quasi-experimental study was conducted with pre-test and post-test measurements in a sample of 62 participants, divided into two groups. One comprised of 30 participants and the other 32 participants. The first one was the control group (CG) on the waiting list and the second was the experimental group (EG), whose members were exposed to a 12-session mindfulness meditation program.

Instruments

Zung Self-rating anxiety scale (SAS)

This scale was developed to assess the frequency of anxiety symptoms. It consists of 20 items, of which one half are formulated in a positive sense and the other half in a negative sense. The respondent indicated how often he or she had experienced each symptom on a four-point Likert scale consisting of ‘‘none or a little of the time’’ (scored as 1), ‘‘some of the time’’ (scored as 2), ‘‘good part of the time’’ (scored as 3), and ‘‘most or all of the time’’ (scored as 4).[11] For the present study, the validity and reliability of the test for the local population were determined using the item-test method, finding values above 0.50 for each item; additionally, the reliability coefficient of 0.84 was found using the split-half method.

Zung Self-rating depression scale (SDS)

This scale consists of 20 items, half in a positive direction and the other half in a negative direction, constructed based on the clinical diagnostic criteria used to characterize depressive disorders. The respondent indicates how often he or she has experienced each symptom on a four-point Likert scale consisting of ‘‘none or a little of the time’’ (scored as 1), ‘‘some of the time’’ (scored as 2), ‘‘good part of the time’’ (scored as 3), and ‘‘most or all of the time’’ (scored as 4).[12] For the present study, the validity and reliability test for the local population was determined using the item test method, finding values above 0.50 for each item; additionally, the reliability coefficient of 0.95 was found using the split-half method.

Perceived stress scale (PSS–14)

This scale is made up of 14 items and measures stressful life situations and circumstances. Respondents are asked to respond on a five-point Likert scale (never = 0; almost never = 1; sometimes = 2; fairly often = 3; very often = 4). Items 4, 5, 7, and 8 were reversed.[13] This instrument presents validity and reliability for the local population.[14]

Procedure

A quasi-experimental study was conducted the participants of which were health sciences students from a public university in Trujillo, Perú. All participants were undergraduate students of two sections (A and B) belonging to the same course. These sections were formed before the researchers’ arrival; for this reason, there was no randomization. Section A was selected as CG and Section B as EG.

Once the groups had been determined, the pre-test was performed using digitized Google forms, and the 12 sessions were scheduled, which were performed weekly with a duration of 60 minutes using a video conferencing platform. An expert meditation teacher led the mindfulness meditation program according to the description in Table 1. In addition, mindfulness meditation audios were provided for daily practice along with compliance report sheets. After the program, the post-test measurement was performed on both groups in the same way as in the initial evaluation [Figure 1].

Table 1

Mindfulness Meditation Program

Session	Description
Week 1	Introduction to mindfulness meditation. The structure of the program. Body scan meditation. Commitment required to successfully complete the program. Distribution of mindfulness meditation audios through Google Drive for daily practice and compliance report sheets.
Week 2	The present moment. Interrupt your automatic pilot. The Raisin Exercise. Homework.
Week 3	Mindfulness of the body with movement including gentle yoga and stretches. Three-minute mindful breathing meditation. Homework.
Week 4	Mindfulness of the breath and body. Body scan meditation. Homework.
Week 5	Mindfulness of breath and body. Sitting meditation. Homework.
Week 6	Being present and calm. Silent meditation. Homework.
Week 7	Dealing with difficulties. Notice thoughts and sensations associated with stress. “Turning Toward” meditation. Homework.
Week 8	Mindfulness and communication. Exploring how stress, anxiety and depression affect the way we communicate. Mountain Meditation. Homework.
Week 9	Mindfulness and communication. The art of listening. The art of being heard. The Lake Meditation. Homework.
Week 10	Mindfulness and compassion. Self-compassion. The Rain Meditation. Homework.
Week 11	Mindfulness and compassion. Cultivating altruism. Loving-kindness meditation to develop kindness and acceptance. Walking Meditation. Homework
Week 12	Mindfulness and gratitude. Gratitude Meditation. Conclusion.

Figure 1

Flowchart of the study

Ethical considerations

Each participant received information about the objectives of the research, and they marked the acceptance of their participation through an informed consent digitized in a Google form sent with the pre-test, where the complete anonymity and the absolute confidentiality of the data were guaranteed. The study protocol was approved by the Institutional Review Board (IRB) according to the ethical guidelines and regulations set forth by the Universidad Nacional de Trujillo under file number 1618576E (RCU N°0361-UNT). This research was carried out according to the principles of the Declaration of Helsinki.

Data analysis

Data were presented as mean ± standard deviation (SD). Means and standard deviations of all variables were determined. Differences in sociodemographic and clinical data from participants were analyzed using the Pearson Chi-squared and Fisher’s exact tests. Man–Whitney U was performed to determine the differences between groups, in addition to using the Wilcoxon test to determine the differences between the study phases. These tests were chosen because data did not conform to the normal distribution. Cohen’s d, Hedges’ g and percentage change were calculated between pre-test and post-test scores. All statistical analyses were performed using SPSS v. 25.0 (IBM Corp., Armonk, NY, USA).

RESULTS

Table 2 presents the sociodemographic and clinical data of the participants analyzed, where the CG was formed by 11 men (37%) and 19 women (63%), while the EG was formed by 14 men (44%) and 18 women (56%). Most of the participants were between 18 and 24 years old in both groups (21 (70%) in the CG and 25 (78%) in the EG, respectively) and the rest were between 25 and 36 years old (9 (30%) in the CG and 7 (22%) in the EG, respectively). These results showed no statistically significant differences (P > 0.05), upon performing the Chi-squared test. In addition, most were unmarried and only one participant was married who belonged to the CG. Finally, most of the participants never attended treatment—26 (87%) for the CG and 29 (91%) for the EG—while 4 (13%) of the participants in the CG and 3 (9%) in the EG attended psychological treatment; no one attended the psychiatrist for pharmacological treatment. These results also did not show statistically significant differences (P > 0.05) upon using Fisher’s exact test.

Table 2

Sociodemographic and clinical data of participants in the study

Sociodemographic data	CG	EG	P
Gender
Male	11 (37%)	14 (44%)	0.570a
Female	19 (63%)	18 (56%)
Age (years)
18-24	21 (70%)	25 (78%)	0.465a
25-36	9 (30%)	7 (22%)
Marital status
Married	1 (3%)	0 (0%)	0.484b
Unmarried	29 (97%)	32 (100%)
Clinical treatment provided
Psychological	4 (13%)	3 (9%)	0.703b
Pharmacological	0 (0%)	0 (0%)
None	26 (87%)	29 (91%)

Pa-value is calculated by Pearson Chi-squared test. Pb-value is calculated by Fisher’s exact test

Table 3 shows the pre-test and post-test differences between the CG and the EG calculated with the Man—Whitney U test, where in the pre-test, there were no significant differences between both groups (P > 0.05), while in the post-test, there were statistically significant differences between the CG and the EG (P < 0.05). Likewise, the scores given by the Wilcoxon test showed no significant differences (P > 0.05) between the pre-test and post-test phases in the CG scores, while statistically significant differences were denoted in the EG scores (P < 0.05).

Table 3

Pre-test and post-test differences between the control group and the experimental group

Groups	Pre-test		Post-test		P b
	Mean	SD	Mean	SD
GC
Stress	26.83	±2.98	27.60	±2.43	0.189
Anxiety	62.97	±4.93	63.03	±4.96	0.952
Depression	56.10	±4.18	56.83	±4.20	0.437
Pa
GE
Stress	26.97	±2.95	22.47	±5.25	0.000*
Pa	0.994		0.000*
Anxiety	63.78	±3.99	58.38	±5.94	0.002*
Pa	0.692		0.005*
Depression	56.88	±4.72	53.94	±6.40	0.000*
Pa	0.576		0.005*

*P<0.05. Pa-value is calculated by Mann-Whitney U test between groups. Pb-value is calculated by Wilcoxon test between study phases

On the other hand, Table 4 shows the scores obtained by Cohen’s d test, Hedges’s g and the percentage change found, where values between 0.5 and 1 show moderate changes, as is the case with anxiety (d = 0.849; g = 0.847) and depression (d = 0.533; g = 0.530); while values higher than 1 show important changes, as evidenced for the stress variables (d = 1.254; g = 1.240). Likewise, the percentage change showed that stress obtained a percentage change of -16.69%, anxiety -8.47%, and depression -5.17%.

Table 4

Cohen’s d, Hedges’ g, and percentage change in intervention groups

Experimental Group	Cohen’s d	Hedges’ g	Percentage change (pretest-posttest)
Stress	1.254	1.240	-16.69%
Anxiety	0.849	0.847	-8.47%
Depression	0.533	0.530	-5.17%

DISCUSSION

The global COVID-19 pandemic has generated various concerns. Its impacts on various human activities are significant, and consequently one of the affected areas is mental health.[15] In this sense, to find effective solutions, the online mindfulness program was performed, observing a decrease in stress, anxiety, and depression in the experimental group after intervention, which coincided with other interventions performed with an online methodology where a decrease in stress and anxiety was also found[1617]; as well as in depression.[18]

In this regard, online mindfulness programs can also be beneficial and can bridge current gaps in mental health needs.[19] Besides, a comparative study evaluated the face-to-face and online modalities of a stress reduction program based on mindfulness, determining that both modalities significantly reduced general psychological discomfort. However, there was no significant difference in terms of stress reduction, also stating that the face-to-face modality obtained highest levels of adherence and satisfaction.[20]

Likewise, mindfulness is considered one of the third generation cognitive behavior therapies,[21] which is focused on processes related to psychological acceptance, values, spirituality and transcendence.[22] Consequently, this therapy tends to change the relationship between the individual and his or her thoughts and feelings.[23] Thus, in the EG, moderate changes were observed for anxiety and depression, which means moderate efficacy for these variables; but in the case of stress, significant changes were reported, which denotes a greater efficacy of the program for this variable, obtaining higher percentage change values, which was in accordance with an investigation that confirmed that mindfulness can improve stress response.[24]

Indeed, mindfulness practice can generate physiological changes such as decrease in blood pressure, decrease in oxygen consumption levels and respiratory rate. These changes can activate the parasympathetic system, producing a sensation of calm, relaxation, and improve emotional self-regulation.[25] Furthermore, mindfulness also reduces the activation of the hypothalamic-pituitary-adrenal (HPA) axis, producing a regulation of cortisol.[26] It also reduces the peripheral physiological stress-response cascade in the sympathetic-adrenal-medullary (SAM) axis. This can inhibit the fight-or-flight stress response.[27]

Besides, mindfulness practice helps to develop positive behavioral facets such as a non-judgmental attitude. This is considered the strongest predictor of lower levels of stress, anxiety, and depression in non-clinical and non-meditating populations.[28]

Mindfulness training promotes emotional regulation; this is related to the activation of the prefrontal regulatory regions in the brain, which can inhibit amygdala activity. This is a crucial point in decreasing anxiety levels.[29]

It is remarkable to say that Beck’s theory of anxiety and depression affirms that maladaptive self-representations are the key contributors to affective disorders.[30] In the case of depression, negatively biased thoughts trigger rumination; however, investigations show an inverse relationship between rumination and mindfulness. That is, when people increase mindfulness skills, they can notice ruminative thoughts at an earlier stage, and so subsequently, can disengage from such thought patterns.[31]

Finally, it should be emphasized that the results are limited to the context studied due to the small sample size. Thus, larger studies must be carried out to be able to generalize the results, as well as to determine a follow-up evaluation in order to observe if these results are maintained over time, and perform the evaluation of these variables with sociodemographic factors and related biochemical parameters as well, in order to better specify the findings, and to determine the mechanisms of action of mindfulness.

CONCLUSION

Despite the limitations, the results show a potential for mindfulness to reduce stress, anxiety, and depressive symptoms in stressful situations, such as during the COVID-19 pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.