The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review

Marcelo M.P. Demarzo; Jesús Montero-Marin; Pim Cuijpers; Edurne Zabaleta-del-Olmo; Kamal R. Mahtani; Akke Vellinga; Caterina Vicens; Yolanda López-del-Hoyo; Javier García-Campayo

doi:10.1370/afm.1863

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Figure 1
Flow diagram of article selection.
MBI = mindfulness-based intervention.
Note: An article may have been excluded for multiple reasons.
^aReferences were fully screened to prevent missing studies.
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Figure 2
Forest plot for the effect size of mindfulness-based intervention on outcomes overall, and for mental health and quality of life outcomes individually.
AC = active control; BDI-IA = Beck Depression Inventory IA; POMS = Profile of Mood States; PC = passive control.

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Table 1

Search Strategy

(“Mindfulness”[MH] OR mindful*[tiab] OR Zen[tiab] OR Vipassana[tiab] OR acceptance-based[tiab] OR “commitment therapy”[tiab] OR DBT[tiab] OR MBSR[tiab] OR MBCT[tiab]) AND (“Primary Health Care”[MH] OR “Family Practice”[MH] OR “General Practice”[MH] OR “General Practitioners”[MH] OR “Physicians, Family”[MH] OR “Community Health Services”[MH] OR “Community Health Nursing”[MH] OR “Community Health Centers”[MH] OR “Community Medicine”[MH] OR “primary health care” OR “primary care” OR ((family OR general) AND (practi* OR physician*)) OR (community AND (medicine OR services OR nursing OR center* OR center*))).

Note: Shown is the complete search strategy for Medline, which was adapted for each database as necessary.

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Table 2

Characteristics of the Included Trials

Trial, Year, Country	Population	Age, Mean (SD) or (IQR), y	Female, %	Intervention	Control	Setting	Professional/Therapist	Time Points	Completion Rate, %^a	Outcomes	Trial Quality^c	Intervention Quality
Plews-Ogan et al³⁷ 2005 United States	Patients with chronic musculoskeletal pain	All groups: 46.5 (SD not given)	76.7	MBSR 8 weeks 2.5 hours/week Face to face and audio (n = 10) Face to face and audio (n = 54)	Usual care (PC) (n = 10) Massage (AC) (n = 10)	Not given	Training and experience not given	Posttest 4 weeks	I: 50.0 PC: 80.0 AC: 90.0	VAS pain and unpleasantness SF-12 global mental health	AS (+) CA (−) PK (−) IO (−)	Manual (+) Training (−) Integrity check (−)
Moritz et al³⁶ 2006 Canada	Patients with mood disturbance (≥40 on POMS)	I: 43.6 PC: 43.9 AC: 44.6 (SDs not given)	83.6	MBSR^b 8 weeks 1.5 hours/week	Wait list (PC) (n = 55) Spirituality program (AC) (n = 56)	CINIM	Not given for MBSR; experienced psychiatrist for spirituality program	Posttest 4 weeks	I: 76.0 PC: 96.0 AC: 75.0	POMS SF-36 Mental Health SF-36 Physical Health	AS (+) CA (+) PK (−) IO (−)	Manual (+) Training (−) Integrity check (−)
de Vibe and Moum³⁹ 2006 Norway	Patients with stress and chronic illness	I: 47 (20–69) PC: 48 (17–63)	88.0	MBSR 8 weeks 2.5 hours/week Face to face and audio (n = 102)	Wait list (PC) (n = 42)	Not given	GPs; training and experience not given	Posttest	92.0	WHOQOL-BREF Global QoL WHOQOL-BREF Global Health WHOQOL-BREF Physical Health WHOQOL-BREF Mental Health WHOQOL-BREF Social Health WHOQOL-BREF Environmental Health Subjective Health Complaint Hopkins Symptom Checklist	AS (−) CA (−) PK (−) IO (−)	Manual (+) Training (−) Integrity check (−)
Kuyken et al⁴ 2008 United Kingdom	Patient with recurrent depression (≥3 previous episodes)	I: 48.95 (10.55) AC: 49.37 (11.84)	47.0	MBCT 8 weeks 2 hours/week Face to face (n = 61)	Usual care (AC) (n = 62)	Primary care; group (9–15 patients)	MBCT therapists: training program taught and supervised by a developer of MBCT	Posttest 15 months	I: 85.0 AC: 84.0	Recurrence Depression BDI-II Hamilton Rating Scale for Depression WHOQOL-BREF Physical Health WHOQOL-BREF Mental Health WHOQOL-BREF Social Health WHOQOL-BREF Physical Health	AS (+) CA (+) PK (+) IO (+)	Manual (+) Training (+) Integrity check (+)
Kitsumban et al³⁸ 2009 Thailand	Elderly women with depression	I: 69.81 (60–80) PC: 68.70 (60–80)	100	CMPP^d 4 weeks/11 sessions 5 six-hour sessions of mindfulness + 6 three-hour sessions of CT Face to face (n = 30)	Usual care (PC) (n = 30)	Local community hall	Primary researcher, educated and trained in CT and mindfulness practice	Posttest 3 months	I: 90.0 PC: 90.0	BDI-IA	AS (+) CA (+) PK (−) IO (−)	Manual (+) Training (+) Integrity check (−)
Van Ravesteijn et al³⁵ 2013 Netherlands	Patients with medically unexplained symptoms	I: 47.0 (13.3) AC: 48.1 (12.3)	75.2	MBCT 8 weeks 2.5 hours/week Face to face and audio (n = 64)	Usual care (PC) (n = 61)	Not given; group (7-14 patients)	Certified and experienced mindfulness teachers	Posttest 9 months	I: 76.0 PC: 90.0	SF-36 Mental Health SF-36 Physical Health General Health Status VAS PHQ-15 Physical symptoms PHQ-9 Depressive symptoms Nonreactivity Five-Facet Mindfulness 14-item Whitely Index Anxiety Observing Five-Facet Mindfulness Describing Five-Facet Mindfulness Acting Five-Facet Mindfulness Nonjudging Five-Facet Mindfulness	AS (+) CA (+) PK (+) IO (+)	Manual (+) Training (+) Integrity check (−)

AC = active control; AS = adequate generation of allocation sequence; BDI = Beck Depression Inventory; CA = concealment of allocation; CINIM = Canadian Institute of Natural and Integrative Medicine; CMPP = cognitive-mindfulness practice program; CT = cognitive therapy; GP = general practitioner; I = intervention; IO = dealing with incomplete outcome data; IQR = interquartile range; MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness-based stress reduction; PC = passive control; PHQ-9 = 9-item Patient Health Questionnaire; PHQ-15 = 15-item Patient Health Questionnaire; PK = prevention of knowledge of the allocated intervention; POMS = Profile of Mood States; QoL = quality of life; SF-12 = Medical Outcomes Study 12-item Short Form Health Survey; SF-36 = Medical Outcomes Study 36-item Short Form Health Survey; VAS = visual analogue scale; WHOQOL-BREF = 26-item World Health Organization Quality of Life scale.
↵a Adequate completion dose was defined as participation in 4 or more sessions.⁴
↵b MBSR was considered a control group in the original study.
↵c Risk of bias: low (+), high (−), or unclear (?).¹⁹
d Considered as MBCT-like in the meta-analysis.

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Table 3

Combined Effect Sizes and Heterogeneity

Characteristic (Number of Trials)	Effect Size, g (95% CI)	P Value^a	Heterogeneity, I² (95% CI)	P Value^b
Total (6)	0.48 (0.18 to 0.77)	.002	59^c (0 to 83)
Outcome
Mental health (5)	0.56 (0.15 to 0.97)	.007	78^d (46 to 91)	.24
Quality of life (5)	0.29 (0.11 to 0.48)	.002	0 (0 to 79)
Intervention
MBSR (3)	0.53 (0.26 to 0.81)	<.001	0 (0 to 90)	.84
MBCT (3)	0.47 (−0.11 to 1.05)	.12	82^d (45 to 94)
Time point
Posttest (6)	0.45 (0.15 to 0.75)	.004	62^c (7 to 89)	.02
Follow-up <6 months (3)	1.08 (0.73 to 1.43)	<.001	0 (0 to 90)
Follow-up >6 months (2)	0.13 (−0.14 to 0.39)	.35	0 (−)
Comparison
Active control (4)	−0.22 (−0.92 to 0.48)	.55	89^e (75 to 95)	.01
Passive control (4)	1.22 (0.36 to 2.07)	.005	90^e (77 to 96)
Disease
Mental (3)	0.62 (0.02 to 1.20)	.04	79^d (32 to 93)	.44
Somatic (3)	0.36 (0.08 to 0.63)	.01	13 (0 to 91)
Intention-to-treat analysis
No (3)	0.75 (0.27 to 1.22)	.002	53 (0 to 86)	.059
Yes (3)	0.24 (0.01 to 0.47)	.04	0 (0 to 90)
Study quality
High (2)	0.15 (−0.11 to 0.41)	.25	0 (−)	.01
Low (4)	0.68 (0.36 to 1.01)	<.001	34 (0 to 77)
World region
Europe (3)	0.29 (0.03 to 0.54)	.03	31 (0 to 93)	.08
Rest of the world (3)	0.77 (0.28 to 1.25)	.002	46 (0 to 89)

MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness-based stress reduction.
Notes: The g value is the Hedges effect size. The I² value is the proportion of real observed dispersion (not calculated for cells having a sample size of fewer than 3 trials).
↵a The P value associated with the effect size.
↵b The P value associated with the mixed effects contrast.
↵c P <.05.
↵d P <.01.
↵e P <.001.

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The Article in Brief

The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review

Javier Garc?a-Campayo , and colleagues

Background Previous research demonstrates positive effects from mindfulness-based interventions in diverse clinical and nonclinical populations. This study analyzes existing research to determine the effectiveness of mindfulness-based interventions in primary care patients.

What This Study Found Mindfulness-based interventions are promising for the mental health and quality of life of primary care patients.

Implications

The number of randomized controlled trials applying mindfulness-based interventions in primary care is still limited and there is insufficient evidence to draw firm conclusions about the effects of such interventions in this setting.