Effectiveness of mindfulness-based stress reduction and mindfulness-based cognitive therapies on people living with HIV: A systematic review and meta-analysis

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Review

Effectiveness of mindfulness-based stress

reduction and mindfulness-based cognitive

therapies on people living with HIV: A systematic

review and meta-analysis

Yang Yang, Yan-Hui Liu

*

, Hong-Fu Zhang, Jing-Ying Liu

School of Nursing, Tianjin University of Traditional Chinese Medicine, China

a r t i c l e i n f o

Article history:

Received 17 March 2015 Received in revised form 10 July 2015

Accepted 29 July 2015

Available online 6 August 2015

Keywords: HIV MBCT MBSR Meta-analysis Mindfulness Systematic review

a b s t r a c t

Objective: To assess the effects of mindfulness-based therapies (MBTs) on the outcomes of people living with HIV.

Methods: During 2014, we searched the PubMed/MEDLINE, Embase, Web of Science, Cochrane Library, and CBM databases to identify randomized and non-randomized controlled studies which compared participants receiving mindfulness-based therapies (MBTs), including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), with participants in control groups. The psychological, biochemical, clinical, and behavioral outcomes of the study participants were analyzed. Two separate reviewers independently performed the study selection, data extraction, and quality assessment tasks, and a meta-analysis of selected studies was performed using RevMan software.

Results: Seven articles describing results obtained with a total of 620 HIV-infected in-dividuals enrolled in six randomized trials and one quasi-experimental trial were included in the final meta-analysis. The overall methodological quality of the studies was moderate, as most study criteria were unclear and subject to a high risk of bias. Patients receiving MBT experienced significantly decreased feelings of stress after 8 weeks (p¼ 0.03) of MBT, and decreased feelings of depression after both 8 weeks (p¼ 0.04) and 6 months (p ¼ 0.02).

Additionally, some patients receiving MBSR training or MBCT showed improved CD4þ

counts at 8 weeks and 6 months, respectively.

Conclusion: While MBT produced psychological benefits in HIV infected patients, any im-provements in CD4þcounts were not robust. Additional studies with longer term follow-up periods and larger sample sizes are required to ascertain the effectiveness of such interventions.

Copyright© 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author.

E-mail address:yh_liu888@163.com(Y.-H. Liu).

Peer review under responsibility of Chinese Nursing Association.

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http://dx.doi.org/10.1016/j.ijnss.2015.07.003

2352-0132/Copyright© 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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1. Introduction

The development of combined antiretroviral therapy has enabled HIV-infected individuals to live for longer periods of time [1]. The WHO and UNAIDS estimated that 35 million

people world-wide were living with HIV at the end of 2013[2].

The HIV virus infects activated CD4þT lymphocytes, causing

their progressive depletion and subsequent defects in the

immune system that lead to various diseases and cancers[3].

In addition to producing physiological effects, the psycholog-ical impact of having HIV/AIDS can affect disease progression as well as a patient's clinical outcome[4]. A recent study[5] reported a higher prevalence of psychological problems, such as feelings of stress, depression, and anxiety, among people living with HIV when compared to people in the gen-eral population. This may be due not only to the illness, but

also to various social factors. The various mental disorders (stress, anxiety, and depression) found among people living with HIV have recently received greater attention by re-searchers. These psychological problems might further sup-press the immune system and accelerate disease progression, causing an HIV-infected individual to develop AIDs more

quickly [6]. Furthermore, such psychological problems can

impair a patient's ability to understand and follow prescribed treatment regimens, leading to poor cART adherence and

treatment results[7]. The WHO has stated that enhancing and

preserving patient quality of life should be a primary outcome goal of contemporary HIV therapy, and that new treatment strategies should produce marked improvements in patient health[8]. Therefore, equipping HIV infected patients with the skills and coping strategies needed manage their physiolog-ical and psychologphysiolog-ical problems has become an integral part of providing comprehensive care to HIV/AIDS patients.

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Mindfulness-based therapies (MBTs) evolved from Western psychology as practiced in the late 1970s. This type of therapy seeks to have people live in the present moment, and be

non-judgmental, accepting, patient, open, curious, kind, and

“non-doing”[9]. It is hoped that through practicing mindfulness,

patients will build the skills needed to pay total attention to the present moment, and accept their physical pain or

psycho-logical distress with a non-judgmental awareness[10]. It has

been suggested that mindfulness exerts its effects via four mechanisms: attention regulation, body awareness, emotion regulation, and changes in perspective regarding one's self[11]. Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are two of the most widely used mindfulness-based therapies, and are designed to

pro-vide therapeutic benefits to people who practice them [12].

MBSR therapy is a structured treatment program originally developed to manage chronic pain, and is now widely used to reduce the incidence and severity of psychological morbidities

associated with chronic illnesses [9]. MBCT, combines

ele-ments of MBSR therapy, cognitive psychology, and cognitive-behavioral therapy, and was initially designed to treat people with a history of recurrent depression. It is currently used to treat emotional and behavioral disorders[13].

The results of previous systematic reviews and meta-analyses have suggested that MBSR training and MBCT might be effective interventions for use in relieving chronic pain[14,15], lowering blood pressure[16], as well as improving psychological health (depression, stress, anxiety), and quality

of life[17e19]. The current systematic reviews concerning the

uses of MBSR training and MBCT have mainly focused on studies involving patients with chronic diseases such as

cancer [19e24], chronic pain [14,25], psychiatric disorders

[17,18,26], cardiovascular diseases [16], and crowd diseases [26e28]. Although the results of some clinical studies inves-tigating the effects of MBSR training and MBCT on people living with HIV have been reported, their findings have not been widely publicized or acknowledged. Our current meta-analysis was performed to assess the short- and long-term effects of MBSR training and MBCT on people living with AIDS, and compare those effects with those provided by control interventions. Such information might provide evi-dence regarding the usefulness of MBSR training and MBCT in promoting the physical and mental health of people living with HIV/AIDS.

2. Methods

2.1. Eligibility criteria

Trials with the following characteristics were included in the meta-analysis.

2.1.1. Types of study designs

Randomized controlled trials (RCTs) and quasi-experimental trials.

2.1.2. Types of participants

Patients diagnosed as HIV-infected, regardless of age, infec-tion durainfec-tion or severity.

2.1.3. Types of interventions

Eligible trials included those that compared patients receiving MBSR training or MBCT with patients in either an inactive control group (no treatment or standard care treatment) or who were receiving some any other type of active treatment. Studies describing interventions that were based on mind-fulness, but were not specifically designated as an MBSR or MBCT program, were excluded.

2.1.4. Types of outcomes

Primary outcomes: CD4þ cell counts, feelings of stress,

distress or depression in the physical and psychological

as-pects of life, respectively. Secondary outcomes: HIVeRNA

load, positive and negative effects of MBT on anxiety, mind-fulness, physical symptomatology, mental health, results shown on a checklist of side effects of HIV infection, and the

impact of those side effects on the patient's physical,

psy-chological, and clinical health. Patient behavioral outcomes and the safety MBT were also assessed.

2.1.5. Length of follow-up

Both the short-term effects (determinations made ~8 weeks after intervention) and long-term effects (determinations made ~6 months after intervention) of MBT were analyzed.

2.2. Search strategy

We used both MeSH terms and free text terms to search the following electronic databases without date restrictions: PubMed/MEDLINE, Embase, Web of Science, the Cochrane Li-brary, and CBM. We also retrieved references cited in the included studies. Studies published in either Chinese or

En-glish were considered, and web sites such as http://

mindfulness teachers uk.org.uk and http://www.mindful experience.org/were searched to find gray literature.

The following strategy is an example of one used to elec-tronically search the PubMed database: (HIV [MeSH Terms] OR Human Immunodeficiency Virus [Title/Abstract] OR AIDS Virus [Title/Abstract] OR Acquired Immunodeficiency Syn-drome Virus [Title/Abstract]) AND (mind body therapies

[MeSH Terms] OR mindfulness [Title/Abstract] OR

Mindfulness-Based Stress Reduction [Title/Abstract] OR MBSR [Title/Abstract] OR mindfulness based cognitive therapy [Title/Abstract] OR MBCT [Title/Abstract]).

2.3. Study selection

After removing duplicated material, two authors indepen-dently screened for titles of articles and abstracts of manu-scripts which satisfied our eligibility criteria. Next, the full-texts of manuscripts were checked to determine if they described trials that should be included in this systematic review. Disagreements between the two reviewers were resolved by a third reviewer.

2.4. Data extraction

Each study's characteristics (participants, interventions, con-trol conditions, outcome measures and findings) were extracted independently by two different reviewers. The

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study investigator(s) was contacted if the required data were not available in their published manuscripts. A third inde-pendent reviewer helped to resolve any disagreements.

2.5. Risk of bias

The Cochrane ‘risk of bias’ tool[29]was used to test for bias and assess the methodological quality of each paper based on six criteria: sequence generation, allocation concealment, blinding of participants, personnel or outcome assessors, completeness of outcome data, and selectivity of outcome reporting. The degree to which a paper satisfied these criteria was assessed by one reviewer, and checked by a second reviewer. A third reviewer was invited to resolve any differ-ences of opinion.

2.6. Data analysis and synthesis

The outcomes of studies were assessed using Review Manager software (Version 5.2, The Nordic Cochrane Centre, Copen-hagen). For continuous outcomes, pooled effects were assessed by calculating their standardized mean differences (SMDs) with 95% confidence intervals (CIs). When two or more groups showed no statistically significant differences at baseline, mean differences (SMDs) were calculated using the final values for the particular outcomes (post-intervention outcomes). When a significant difference existed between an intervention and control group, the standardized mean dif-ference (SMD) was calculated using the difdif-ference in the changes in values from baseline values. The mean change was obtained by subtracting the final mean value from the mean value at baseline. Standard deviations (SDs) for statistical re-sults were calculated using a formula in the Cochrane Hand-book[30]. Correlations between baseline and follow-up values were obtained from a comparable study or by using the

cor-relation coefficient (r¼ 0.5) suggested in the Cochrane

Hand-book[29].

Statistical heterogeneity among the reviewed studies was

quantified by determining values for I2_{; where I}2 _{< 30%,}

I2_{> 50%, and I}2_{> 75% were defined as moderate, substantial,}

and considerable heterogeneity, respectively. To eliminate clinical heterogeneity, we conducted subgroup analyses based on the type of intervention (MBSR therapy or MBCT) and control group used in various studies (active control group or inactive group). Additionally, sensitivity analyses were per-formed by excluding a single study and then comparing the results of studies with a high risk for domain selection bias, detection bias or attrition bias, with the results of studies having a low risk for the selected particular bias. This type of analysis allowed us to obtain more stable results.

3. Results

3.1. Study selection

Our electronic search identified a total of 230 citations for re-ports concerning either MBSR therapy or MBCT. After excluding duplicates, 171 studies satisfied our eligibility re-quirements, and full-text reports were obtained for 31 studies.

Among those 31 studies, 24 did not fulfill our inclusion criteria for one of the following reasons: they did not investigate MBSR

therapy or MBCT (n¼ 14), or HIV-infected patients (n ¼ 6), or

did not include a control group (n¼ 4). Finally, six randomized controlled trials and one quasi-experimental study were included in our meta-analysis[31e37]. No additional trial was later included after retrieving references cited in the original seven included studies. A flow chart describing our search strategy and article retrieval results is shown inFig. 1.

3.2. Study characteristics

The seven included studies (six randomized controlled trials

[31e36] and one quasi-experimental study [37]) were

pub-lished from 2003 to 2014 (Table 1), and were conducted in

Canada [33], Spain[37], Iran [35], and the USA [31,32,34,36],

respectively. The number of participants in the individual studies ranged from 34 to 173, and a total 620 participants were enrolled in all seven studies. All study participants had been diagnosed as HIV/AIDS, and the experimental group in each study received intervention with MBCT or MBSR training.

Regarding control groups, three trials[32,35,36]incorporated

an active control treatment which was either a 1-day seminar or Education and Support (ESC) meeting. The remaining four

studies [31,33,34,37] incorporated either a placebo group or

standard control group (TAU, routine follow-up, wait-list control or comparison group). All study participants were 25e64 years old.

3.3. Intervention characteristics

MBSR training was used in six studies[31e36]and MBCT in

one study[37]. Both types of therapy were administered for

1.5e2.5 h/week during a program that lasted 8 or 10 weeks. Additionally, the participants performed a daily homework

assignment which required 30e43 min of time each day, six

days per week. There was little variation among the in-terventions used in the seven included studies.

3.4. Study quality (risk of bias)

We used the Cochrane risk of bias tool to assess the meth-odological quality of five randomized controlled trials, and the

results are presented inFig. 2. We found that two studies did

not report details of their randomization methods[32,35]. In

another study, a blinded design could not be used due to the nature of MBT, and only one study reported that participants

were blinded to outcome assessments [32]. Five studies

re-ported unbalanced or unreasonable participant withdrawals, and only two studies included an intention-to-treat analysis [33,34]. Based on criteria in the Cochrane Handbook, we were unable to assess our meta-analysis for publication bias because there were<10 included studies.

3.5. Outcomes

The seven studies in our meta-analysis reported five types of

outcomes, which included psychological symptoms

(perceived stress [31,33,34], anxiety [33,37], depression

[33,34,37], mindfulness [34], positive-negative affect [34]),

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biochemical indicators (i.e. CD4þcount[32,35,37]), quality of life[37], clinical outcomes[35], and behavioral outcomes[37]. Additionally, the safety of MBT intervention was also assessed.

3.5.1. Psychological outcomes

Four trials (with 216 participants receiving MBSR training in

three trials[31,33,34]and 39 participants receiving MBCT in

one trial [37]) used the perceived stress scale (PSS-10) to

examine the effects of MBT on psychological stress (Figs. 3 and 4). Our meta-analysis analysis revealed a significant differ-ence between an MBT group and a control group concerning

their levels of stress starting at 6 months (SMD¼ 0.85, 95%

CI:1.61 to 0.08, p ¼ 0.03). Moreover, a subgroup analysis

across different types of intervention also indicated that MBSR training could reduce patient stress after 6 months of practice (SMD¼ 0.41, 95% CI: 0.71 to 0.11, p ¼ 0.007). Additionally, MBCT produced significant effects on stress in both the

short-(SMD¼ 1.18, 95% CI: 1.86 to 0.49, p ¼ 0.0008) and

long-term (SMD¼ 2.00, 95% CI: 2.84 to 1.17, p ¼ 0.000) time

frames.

Our meta-analysis of three RCTs (two using MBSR training [33,34] and one using MBCT [37]) showed that MBT signifi-cantly improved symptoms of depression in both the

short-term and long-short-term (SMD¼ 0.35, 95% CI: 0.68 to 0.01,

p¼ 0.04; SMD ¼ 0.47, 95% CI: 0.86 to 0.08, ¼ 0.02,

respec-tively). Furthermore, a subgroup analysis across interventions showed that MBSR training produced a statistically significant

long-term effect (SMD ¼ 0.31, 95% CI: 0.61 to 0.01,

p¼ 0.04). The study conducted by Gonzalez-Garcia showed

that MBCT had a positive effect on depression in both the

short-term and long-term (SMD ¼ 0.83, 95% CI: 1.49 to

0.17, p ¼ 0.01; SMD ¼ 1.02, 95% CI: 1.74 to 0.30, p ¼ 0.005, respectively;Figs. 5 and 6). Two trials measured the effects of

MBT on patient anxiety using the Hospital Anxiety and

Depression Scale (HADS)[33]and the Beck Anxiety Inventory

(BAI)[37], respectively. The results showed that MBCT may

have had a slight long-term (6 months) effect on anxiety

(SMD¼ 0.74, 95% CI: 1.43 to 0.04). Previously, both Duncan

et al.[34]and Gayner et al.[33]used the Positive and Negative Affect Schedule (PANAS) to analyze the positive and negative effects of MBSR training. Our meta-analysis revealed that MBSR had positive effects on people living with HIV after 6

months of training (SMD¼ 0.42, 95% CI: 0.08e0.76, p ¼ 0.01).

Additionally, Duncan et al.[34]and Gayner et al.[33]used the Five Factor Mindfulness Questionnaire (FFMQ) and The Mindfulness Measure (TMS), respectively, to measure changes

in mindfulness. Duncan et al. [34]reported on four factors

examined by the FFMQ, and Gayner et al. reported that par-ticipants in an MBSR group experienced significantly increased levels of mindfulness after 8-weeks of training

(SMD¼ 1.16, 95% CI: 0.75e1.57, p ¼ 0.00) and also during a

6-month follow-up period (SMD ¼ 0.75, 95% CI: 0.35e1.15,

p¼ 0.00).

3.5.2. Biochemical outcomes

Three trials reported CD4þcell counts for their participants. Two of the trials used an active control design[32,35]and one

used an inactive control design [37]. The pooled results of

these two trials can be seen inFigs. 7 and 8. There was no

significant difference between the CD4þ counts of patients

who received MBT and control subjects at either an 8-week or 6-month time period. A subgroup analysis revealed an

in-crease in CD4þ cell counts only in the study conducted by

Gonzalez-Garcia et al. [37], and that increase occurred at 6

months (SMD¼ 0.76, 95% CI: 0.07e1.46, p ¼ 0.03).

Two trials reported the effect of MBT on HIV RNA levels, and neither study found any difference between experimental

Fig. 1e Flow chart showing search results and article retrieval.

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Table 1e Characteristics of the included studies.

Study Design Participants Interventions Controls Follow-up

(months) Outcomes and tools Findings Robinson et al., 2003 USA [31]

CCT 34 (32 males, 2 females), with a mean age of 43.08± 6.07 years in the MBI group and 36.10± 8.03 years in the control group

MBSR: 8 consecutive weekly sessions, lasting 2.5 h each, 1 full-day (8 h) session, and individual pre-test and post program interviews; daily practice 45 min

e ① Perceived stress: PSS;

② Mood States: POMS; ③ Functional assessment: FAHI; ④ Immune response: NK cell activity; RANTES; SDF-1 ⑤ Endocrine response: DHEAS; Cortisol; Cortisol/DHEAS

① Significant differences be-tween

groups regarding NK cell activity and numbers at 8 weeks; ② No significant difference be-tween groups regarding perceived stress,

mood states, endocrine, or func-tional health variables at 8 weeks.

Creswell et al., 2009 USA

[32]

RCT 48 (43 males, 5 females), with a mean age of 40± 9 years in the MBI group and 42± 11 years in the control group

MBSR: 8 weekly 2 h group sessions, a day-long retreat in the 7th week; daily home mindfulness meditation practice.

Control seminar: 1-day seminar

e ①CD4 cell counts and HIVe

RNA viral load; ② MBSR treatment adherence;

① A significant difference be-tween

groups regarding CD4 cell counts; ② No significant effects on HIV RNA.

Gayner et al., 2012 Canada

[33]

RCT 117 HIV gay men with an age range of 25e64 years

MBSR consisting of eight 3-h weekly sessions and a day-long retreat with about an hour or more of homework per day, 6 days per week.

ATU 6 ①Distress: IES;

② Anxiety & depressive: HADS,

③ Positive affect and nega-tive

affects: PANAS; ④ Mindfulness: TMS

① A significant reduction in scores

on the IES avoidance sub-scale; ② A significant difference be-tween

groups in positive effects at 8 week

and 6 month follow-up evaluations

③ No significant difference in depression, anxiety, and the IES intrusion sub-scale scores between

groups;

④ A significant increase of mindfulness among participants in the intervention group at the 8-week and 6 month follow-up evaluations.

Duncan et al., 2012 USA

[34]

RCT 76 (64 males, 12 females), with a mean age of 47.9± 6.8 years in the MBI group and 48.2± 9.1 years in the control group

MBSR: A standardized series of 8 weekly sessions of 2.5e3 h; daily home assignments of mindfulness practice

WLC 6 ①Side effects: AIDS Clinical

Trials Group symptom checklist;

②Adherence to ART; ③ Depression: BDI ④ Perceived stress: PSS ⑤Positive and negative affect: PANAS; ⑥Mindfulness: FFMQ

① MBSR reduced both the frequency of symptoms attribut-able

to ART and the distress related to HIV side effects;

② No significant differences between groups regarding adherence, perceived stress, depression, positive and negative affect, and mindfulness. interna t iona l j o u rnal of nur s ing s ciences 2 (2015) 283 e 294

288

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SeyedAlinaghi et al., 2012 Iran

[35]

RCT 171 (118 males, 53 females), with a mean age of 34.7± 6.1 years in the MBI group and 45.6± 6.9 years in the control group

MBSR is an eight-week group-based course in mindfulness meditation, and is described in the original MBSR manual

ESC 3, 6, 9, 12 ① CD4 count; ② Physical Symptom-atology: MSCL 37; ③Mental health: SCL-90R ① A significant difference in CD4þ

counts between groups at 8 weeks,

3 months, 6 months and 9 months;

② A significant difference in Physical Symptomatology be-tween groups at 8 weeks, 3 months, 6 months, and 12 months;

③ A significant difference in the mental health of groups at 8 weeks,

3 months, 6 months, 9 months, and 12 months; Weston et al., 2012 USA [36] RCT 132 HIVþ adults (71 MBSR, 61 control) with CD4þ counts> 250 cells/mL.

MBSR ESC 3, 12 High sensitivity C-reactive

protein (hsCRP); D-dimer

No effect on hsCRP or

D-dimer levels at 3 or 12 months (p> 0.10)

Gonzalez-Garcia et al., 2013 Spain

[37]

RCT 40 HIV infected participants (20 males,

20 females), with a mean age of 49.4± 5.1 years

MBCT: 2.5 h per week over 8 weeks A minimum of 45 min/day and 6 days/week

Routine 5 ① CD4 cell counts and HIV

e RNA l load; ② Perceived stress: PSS-10; ③Depression: BDI-II ④Anxiety: BAI ⑤Quality of life: NHP; ⑥ Adherence to cART, healthy diet, and smoking secession;

① A significant difference be-tween

groups regarding CD4 cell counts at week 20.

② A significant difference be-tween

groups regarding stress, depres-sion,

anxiety, and quality of life at weeks

8 and 20.

③ No significant difference be-tween groups regarding the level of HIVe

RNA, adherence to cART, eating a healthy diet or smoking at weeks 8 and 20.

Note: Mindfulness-based Stress Reduction (MBSR); Mindfulness-based Cognitive Therapy (MBCT); Treatment-As-Usual (TAU); a wait-list control (WLC); antiretroviral therapy (ART); Education and Support (ESC); The Impact of Event Scale (IES); The Hospital Anxiety and Depression Scale (HADS); The Positive and Negative Affect Schedule (PANAS); The Toronto Mindfulness Scale (TMS); Not-tingham Health Profile (NHP); Perceived Stress Scale (PSS-10); Beck Depression Inventory (BDI-II); Beck Anxiety Inventory (BAI); Five Factor Mindfulness Questionnaire (FFMQ); The Medical Symptom Checklist (MSCL (37)); The Symptom Checklist-90-Revised (SCL-90R (41)).

international j ournal of nursing s ciences 2 (2015) 283 e 294

289

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and control groups after 8 weeks of MBSR training.

Addition-ally, Weston et al. [36]showed that MBSR training did not

affect the levels of high sensitivity C-reactive protein (hsCRP)

and D-dimer in participants at 3 and 12 months (p> 0.10

compared with the control group).

3.5.3. Quality of live, clinical outcomes, and behavioral outcomes

A study by Gonzalez-Garcia et al.[37]revealed a significant

improvement in patient quality of life at both 8 weeks

(SMD¼ 23.30, 95% CI: 37.67 to 8.93, p ¼ 0.001) and 20

weeks (SMD¼ 32.7.30, 95% CI: 46.52 to 18.88, p ¼ 0.000).

Furthermore, Seyed Alinaghi et al.[35]reported significantly

enhanced physical and mental outcomes in a group of pa-tients receiving MBSR training when compared with a group receiving Education and Support (ESC); additionally, the favorable effects were sustained for up to 12 months. How-ever, that study found no significant difference between the

two groups regarding their behavioral outcomes as

demonstrated by cART adherence, eating a healthy diet, and smoking after the intervention[37].

3.5.4. Safety

While no trial in our meta-analysis reported adverse events, a total of 42 participants dropped out of studies due to dissat-isfaction with the program, health issues, emotional issues, or the amount of time required and intensive nature of the program.

4. Discussion

4.1. Summary of main results

This is the first systematic review and meta-analysis to examine the effects of MBSR training and MBCT on psycho-logical outcomes, biochemical parameters, quality of life, clinical outcomes, and behavioral outcomes, in HIV infected patients. Our results indicate that MBT decreased the levels of stress in patients at 8 weeks, and decreased symptoms of depression at 8 weeks and 6 months.

4.2. Applicability of evidence

HIV infection is characterized by huge variability in the onset age, a variety of clinical symptoms, and a long period of illness. Additionally, HIV/AIDs patients often suffer from serious physical and psychological conditions. The trials included in our meta-analyses were conducted in both developed and developing countries. Furthermore, they enrolled both young and adult patients with a confirmed HIV infection, as well as patients with different levels of disease severity. Some of the patients were receiving antiretroviral therapy, while others were not. Because our analysis included a wide range of populations, it could be argued that our results apply to the majority of people living with HIV/AIDs.

4.3. Quality of evidence

This analysis included a small number of trials, and only one trial reported the effect of MBCT on people infected with HIV. This indicates that the use of mindfulness therapy in treating Fig. 2e Risk of bias for included studies.

Fig. 3e Forest plot showing the short-term effects of MBSR/MBCR on stress (8 weeks).

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HIV remains in an exploratory phase. Additionally, the overall quality of evidence provided in the included studies was low, and our results may have been affected by bias.

4.4. Agreement and disagreement with other systematic reviews

Our findings regarding the ability of MBT to decrease stress in HIV-infected patients on a long-term basis were in agreement with findings in Chiesa and Serretti's study[26], which found no significant difference in long-term stress reduction in healthy individuals assigned to an MBT intervention group or

control group. However, another study[38]reported that MBT

had a small effect size (0.32) on reducing stress in adults with chronic conditions. Reviews of studies conducted with cancer patients suggested an even more significant effect of MBT on patient stress (overall effect sizes of 0.58e0.71)[20,21].

Our results showed that MBT was marginally beneficial for

relieving symptoms of depression (SMDs¼ 0.35 for 8 weeks

and 0.47 for 6 months), and this result was similar to previ-ously reported findings[15,17]. Additionally, Strauss et al.[17] reported findings that were consistent with ours from a sub-group analysis conducted across MBCT and MBSR training. In that subgroup analysis MBCT, but not MBST, was shown to be

Fig. 5e Forest plot showing effects of MBSR/MBCR on depression (8 weeks).

Fig. 4e Forest plot showing the short-term effects of MBSR/MBCR on stress (6 months).

Fig. 6e Forest plot showing effects of MBSR/MBCR on depression (6 months).

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significantly effective for treating depression. Originally, MBCT was found to be effective for reducing the incidence of

relapse among people who had experienced3 episodes of

depression[39]. Our review provides additional evidence that

MBCT might also be effective in people with a current diag-nosis of a depressive disorder.

Our meta-analysis included only a small number of studies concerning the effect of MBT in treating anxiety, which makes the findings less than robust. Our negative results regarding the effects of MBT on anxiety were consistent with those

re-ported by both Strauss et al.[17]and Lakhan and Schofield

[15]. However, another previous meta-analysis found a mod-erate to high effect size of anxiety among people with chronic

diseases, and also breast cancer patients (SMDs¼ 0.47 and

0.51e0.73, respectively)[20,25,38].

Regarding biomedical outcomes, some previous studies reported that MBSR training could increase plasma cortisol

levels, extend cell longevity[40,41], promote the recovery of

functional T cells[42], and improve plasma levels of IGF-1 and

antigen-specific IgM and IgG 3[43]. These results compliment

our finding regarding the effect of MBT on CD4þ counts.

Additionally, two pilot trials[45,46]reported that MBSR

ther-apy significantly improved both the CD4þ counts and

psy-chological status of people living with HIV. MBSR training not only improved the attitudes (less negativity) of the patients, but also decreased their degrees of reactivity and impulsivity,

improved their levels of self-care, and increased their perceived value of socializing with other people. Finally,

Gal-legos et al.[44]recently reported that MBSR training might

benefit the hypothalamicepituitaryeadrenal (HPA) axis and

improve the emotional outcomes of older adults.

5. Limitations

Our meta-analysis has some limitations that should be mentioned. The first limitation concerns the experiment

design; as only three studies [32,35,36] included an active

control group and the other four studies had an inactive

control group[31,33,34,37]. Future studies should include an

active control therapy to better demonstrate the benefits of MBT. Second, the studies in our meta-analysis were of only of moderate methodological quality, because their criteria were unclear, and their design permitted a high risk of bias, which inevitably affected the results of our analysis. Third, four studies only used only six months as a cut-off time for judging the long-term effects of therapy, while one trial used a 12 month time period for this purpose. For people living with HIV and experiencing a current episode of physical or mental disorders, a considerably longer followup period would allow for a more precise evaluation of the long-term effects of a therapy. Fourth, although we used a comprehensive search

Fig. 8e Forest plot showing effects of MBI on CD4þ_{counts at 6 months.}

Fig. 7e Forest plot showing effects of MBI on CD4þ_{counts at 8 weeks.}

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strategy to retrieve existing trials, due to language and other limitations, only seven studies were included in our analysis, and this might have influenced the robustness of our evi-dence. Lastly, due to geographical and cultural differences, the results of the included studies might not be directly applicable to Chinese HIV/AIDS patients; therefore, clinical practitioners should consider racial and cultural differences when attempting to apply our results.

6. Implications for further research

Reich et al.[47]reported that the baseline biomarkers of study participants can influence the benefits they receive from MBSR training, and that adherence to an intervention protocol is also a key factor for ensuring that patients benefit from

MBSR therapy[36,48]. Although our meta-analysis contained

no information regarding protocol adherence, our findings clearly showed that MBT was more effective for treating stress and depression than for treating anxiety. Therefore, we caution against offering MBT as a first line intervention to people experiencing a primary anxiety disorder. Additionally, MBCT was better than MBSR therapy for improving symptoms of depression among people living with HIV, indicating that intervention methods should be carefully selected and based on specific symptoms exhibited by a patient.

7. Conclusions

This systematic review showed that MBT had a long-term effect on stress and both a short- and long-term effect on depression in people living with an HIV infection. Our results

concerning the effects of MBT on anxiety and CD4þcounts in

intervention and control groups were ambiguous. More robust studies with longer follow-up times are required to establish the actual efficacy of MBT intervention in HIV/AIDS patients.

Author contributions

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important

intellectual content.

Conflict of interest

No conflict of interest has been declared by the authors.

Acknowledgments

There was no financial support for this research.

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Effectiveness of mindfulness-based stress reduction and mindfulness-based cognitive therapies on people living with HIV: A systematic review and meta-analysis

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