Literature Review
zsttrobes
1.mindfulnessondepression.pdf
O R I G I N A L R E S E A R C H
Effects Of Modified Mindfulness-Based Stress
Reduction (MBSR) On The Psychological Health
Of Adolescents With Subthreshold Depression:
A Randomized Controlled Trial This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment
Jia-Yuan Zhang 1, *
Xiang-Zi Ji 2, *
Li-Na Meng 1
Yun-Jiang Cai 1
1Department of Psychological Nursing
Science, Harbin Medical University,
Daqing, Heilongjiang Province, People’s Republic of China; 2Department of
Nursing Science, Suzhou Vocational
Health College, Suzhou, Jiangsu Province,
People’s Republic of China
*These authors contributed equally to
this work
Background: Sub-threshold depression (SD) has been associated with impairments in
adolescent health which increase the rate of major depression. Researchers have shown the
effectiveness of mindfulness on mental health, however whether the traditional mindful skills
were suitable for youngsters, it was not clear. This study investigated the effects of a tailed
Mindfulness-based stress reduction (MBSR) on their psychological state.
Methods: A double-blind, randomized controlled trial was carried out. 56 participants who
met the inclusion criteria agreed to be arranged randomly to either the MBSR group (n=28)
or the control group (n=28). Participants in MBSR group received a tailored 8-week, one
time per week, one hour each time group intervention. The effectiveness of intervention was
measured using validated scales, which including BDI-II, MAAS, RRS at three times (T1-
before intervention; T2-after intervention; T3-three months after intervention). A repeated-
measures analysis of variance model was used to analyze the data.
Results: The results showed significant improvements in MBSR group comparing with
control group that depression level decreased after the 8-week intervention and the follow up
(F =17.721, p < 0.00). At the same time, RRS score was significantly decreased at T2 and T3
(F= 28.277, p < 0.00). The results also showed that MBSR promoted the level of mind-
fulness and the effect persisted for three months after intervention (F=13.489, p < 0.00).
Conclusion: A tailored MBSR intervention has positive effects on psychology health
among SD youngsters, including decrease depression and rumination level, cultivate
mindfulness.
Keywords: mindfulness, adolescent, subthreshold depression
Introduction Subthreshold depression (SD), also known as subsyndromal depression, subclinical
depression, or mild depression, refers to a state or a subpopulation of individuals
who have certain depressive symptoms but do not meet the diagnostic criteria for
major depressive disorder.1 A previous study found that the incidence of subthres-
hold depression was significantly higher than that of major depressive disorders,
with an estimated prevalence rate of 25% worldwide, and it had a serious impact on
individual life and social psychological function.2 However, there is little agree-
ment on how to address the diagnosis of subthreshold depression; modern classi-
fication systems such as the Diagnostic and Statistical Manual of Mental Disorders,
Correspondence: Li-Na Meng; Yun-Jiang Cai Department of Psychological Nursing Science, Harbin Medical University, No. 39 XinYang Street, Daqing, Heilongjiang Province 163319, People’s Republic of China Email [email protected]; [email protected]
Neuropsychiatric Disease and Treatment Dovepress open access to scientific and medical research
Open Access Full Text Article
submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2019:15 2695–2704 2695 DovePress © 2019 Zhang et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
http://doi.org/10.2147/NDT.S216401
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
Fourth Edition (DSM-IV) have established diagnostic
categories for subsyndromal depressive symptoms, includ-
ing “dysthymia,” “brief recurrent depression,” and “minor
depressive disorder”.3 Subthreshold depression is consid-
ered to be the precurative stage of major depressive dis-
order and can predict the occurrence of major depressive
disorder in individuals in the future. It should be made
clear that it is increasingly recognized that individuals with
subthreshold depression do not have a similar prognosis to
those who are asymptomatic, and are in fact at elevated
risks of later depression and suicidal behaviors.4
Individuals with subthreshold depression have an odds
ratio of more than 5 for having a first lifetime episode of
major depression disorder.5 Meanwhile, subthreshold
depression has also increased the risk of adverse outcomes
such as drug abuse and dependence. In recent years, the
incidence of subthreshold depression in adolescents has
grown rapidly and as high as 36.56%.2 There are adoles-
cents with subthreshold depression who have not yet met
the diagnostic criteria for depression, but subthreshold
depression has caused a decline in their social function
and has placed them at a higher risk of experiencing
depressive episodes, which should be highly concerning.6
However, there are limited studies focus on investigating
an effective and feasible way to help adolescents with
subthreshold depression improve their psychological
health.
Mindfulness, derived from Buddhist meditation, is
described as a state of being purposeful and giving non-
judgemental attention to the present moment. Its core
elements are “the ability to focus on the present” and
“keep a curious, open and receptive attitude”.7
Mindfulness intervention is a psychological treatment,
which refers to a series of psychological training methods
based on “mindfulness,” that can help individuals cultivate
and enhance mindfulness. In the late 1970s, American
psychologist Kabat-Zinn introduced and developed mind-
fulness-based stress reduction (MBSR) psychotherapy,
which was praised as “the third wave of behavioral and
cognitive therapy”.8 MBSR is a systematic non-drug psy-
chological therapy that includes four basic mindfulness
skills. Through mindfulness meditations, body awareness
and yoga, MBSR can awaken inner mindfulness and
improve self-regulation to help people relieve stress. At
present, MBSR has been widely used in medical treatment
and has become an important part of the biopsychosocial
approach medical system to promote psychology and phy-
sical health.9 Studies have shown that MBSR can alleviate
anxiety and depression among cancer patients.10,11
A recent meta-analysis showed that yoga-based interven-
tions, including mindfulness practice, had significant ben-
eficial effects for pregnant women with mild depressive
symptoms.12 However, due to differences in cultural and
religious beliefs and economic levels, whether MBSR is
suitable for the Chinese adolescent population needs
further investigation.
Mindfulness therapy includes formal and informal tech-
niques. The traditional form of mindfulness-based stress
reduction therapy is group intervention. Each group is lim-
ited to approximately 30 people with 8 practice times of 2
to 2.5 hrs each.13 However, due to time constraints or hard-
to-grasp core skills, many people suspend or quit psycho-
logical treatment. For adolescents, due to their immature
psychological adjustment mechanism, it is difficult for them
to grasp the core of mindfulness skills related to meditation
in a short amount of time.14 The best way to perform
psychological intervention is to allow adolescents to apply
the techniques to their life and integrate them into their life
over time, thus improving their psychological health. Fewer
studies have focused on the longitudinal effects of mind-
fulness skills on adolescents in China.15 Therefore, a tai-
lored MBSR programme for adolescents with rigorous and
well-controlled randomized trials is needed to further test
the long-term effects of modified MBSR on the psycholo-
gical health of adolescents.
This study was designed to evaluate the effects of a
tailored simplified MBSR on the psychological health of
adolescents with subthreshold depression, including
depression levels, rumination and mindfulness levels, in
a randomized controlled trial. We hypothesized that mod-
ified MBSR training would provide evidence for improv-
ing psychological health, thus decreasing depression and
rumination levels and increasing mindfulness in Chinese
adolescents with subthreshold depression.
Methods Study Design This study was a randomized controlled design with dou-
ble-blind subjects. All participants were divided equally
into the MBSR training group and the control group using
the random number table by staff members who were
independent from the study. All participants received the
anonymous letters and they were blinded to their random
assignment until the end of the session. When the study
was completed, the control group received the same
Zhang et al Dovepress
submit your manuscript | www.dovepress.com
DovePress Neuropsychiatric Disease and Treatment 2019:152696
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
intervention according to their own wishes. The interven-
tion was conducted at the psychological interview room
carried out by a qualified psychologist. The anonymous
data were collected and analyzed by an assistant who was
blinded to the group assignment and all the trials. The
design of the entire study is illustrated in a flow diagram
in Figure 1.
Sample And Setting The sample-size estimation in this study was calculated by
using the G*POWER version 3.1 program with a power
(1−β) of 0.80 in the paired-samples t-test and a signifi-
cance level of 0.05. Based on the related data,16 we estab-
lished an effect size (d) of 0.796; consequently, the total
sample size was 52 participants. Allowing for a 5–10%
dropout rate, we recruited 56 students in September 2017.
Participants were enrolled by putting up a poster on cam-
pus. We used two steps to recruit the participants. First, all
of the interested students completed questionnaires (Beck
depression inventory, BDI and self-rating depression scale,
SDS). Participants who had a BDI>14 and an SDS>53
were defined as the preliminary screening group. Second,
the structured clinical interview for DSM (SCID) was
conducted among the preliminary screening group by a
psychologist to perform the second screening. The exclu-
sion criteria were as follows: i) had recently suffered from
major stress events; and/or ii) had major depressive dis-
order, bipolar disorder or other types of mental illnesses. A
total of 291 students agreed to participate in the study, and
in the end, the study included 56 participants who met the
following inclusion criteria: i) volunteered for this study
and agreed to obey the rules during the intervention and ii)
had subthreshold symptoms of depression (as defined by
the questionnaires and structured interviews). Participants
who had participated in or were participating in similar
interventions (such as yoga or meditation) were also
excluded. All participants provided their written consent.
The study was approved by the institutional review board
at Harbin Medical University (Daqing) and this trial was
conducted in accordance with the Declaration of Helsinki.
Intervention The MBSR Intervention Group
Participants allocated to the MBSR training groups
received 8 weeks of modified MBSR training. Based on
traditional MBSR theory, the intervention was tailored
according to the characteristics of adolescents and empha-
sized teaching them to apply formal techniques such as
body scanning, sitting meditation, and mindfulness yoga to
Figure 1 Study flow diagram: enrollment to analysis.
Dovepress Zhang et al
Neuropsychiatric Disease and Treatment 2019:15 submit your manuscript | www.dovepress.com
DovePress 2697
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
all aspects of the practitioner’s life, including experiencing
the pleasant/sad moments in life, walking, sleeping, eating,
breathing and exercising to keep the attitude of “mind-
fulness”. The intervention plan was designed and adminis-
tered by a qualified psychological expert who has been
involved in MBSR treatment for 5 years. Participants in
the MBSR group were divided into 4 groups with 7 people
per group. Each group received training sessions for 8
weeks, and the sessions occurred once a week for one
hour at a time. Each session included 10 mins of free
talk (feeling about homework), 15 mins of demonstration
and explanation, 20 mins of practice and guidance, and
15 mins of group imitation training. Each session was
followed by homework, which was available for the trai-
ner to understand the practice situation of each person.
Combined with daily activity, the themes of the interven-
tion were derived from “eye”, “ear”, “nose”, “tongue”,
“body” and “thinking”. More details of each session are
listed in Table 1.
The Control Group
Students in the control group continued with their lives as
usual. No specific intervention was implemented in the
control group. To avoid possible overlap (contamination)
with components of the MBSR programme, the students in
the control group who planned to attend related associations
such as yoga clubs during the intervention period (8 weeks)
were excluded. After completion of the study, each student
in the control group was provided with the same MBSR
course according to their own wishes.
Measures Beck Depression Inventory-II (BDI-II)
The primary outcome was the severity of depressive symp-
toms assessed with the BDI-II. The scale was a well-
validated and widely used measure of depression that
assesses the frequency of depressive symptoms over the
previous 2 weeks. It consists of 21 items that are rated on a
4-point scale, with scores ranging from 0 to 63, and cut-off
points of 0–13, 14–19, 20–28 and 29–63, which represent
no, mild, moderate and severe levels of depression, respec-
tively. The scale has been used in the Chinese adolescent
population, revealing good reliability and validity.17
Mindful Attention And Awareness Scale (MAAS)
Participants’ self-reported mindfulness level was measured
with the MAAS.18 The scale contains 15 items that assess
the most important characteristics of mindfulness. Items
are rated on a 6-point scale and scored as (1) almost
always to (6) almost never, with higher scores reflecting
a greater mindfulness state. The scale has been tested
among Chinese college students, revealing good internal
consistency reliability (α=0.85) and test-retest reliability
(r=0.54).19
Ruminative Response Scale (RRS)
The RRS was compiled by Nolen-Hoeksema and assesses
the response to depression. It consists of 22 items rated on
a 4-point scale that are scored as (1) never to (4) very
often, with scores that ranged from 22 to 88. Higher scores
represent a greater level of rumination. It has 3 factors:
symptom rumination, forced thinking and introspection.
The Chinese version of the Perceived Stress Scale
(CPSS) was translated by Han20 and has been tested
among Chinese college students, revealing good internal
consistency reliability (α = 0.90) and test-retest reliability
(r=0.68–0.85).
Procedure After approval from the institutional review board and
ethics committee, we put up a poster on campus for
recruitment. The modified 8-week MBSR intervention
was carried out by a qualified psychologist. The question-
naires were delivered and collected by two staff members
who were independent of our study. All students com-
pleted questionnaires at three points. The first point was
the initial baseline orientation when the MBSR interven-
tion started, the second point was the end of the 8-week
intervention, and the last point was 3 months after the
intervention.
Statistical Methods All data analyses were performed using IBM SPSS 21.0
(version 21.0, IBM Corp., New York, NY, United States)
with bilateral inspection by two dependence assistants.
The continuous variables were assessed by means with
standard deviations or medians with ranges. Baseline
data were compared using a t-test or chi-square test
between the two groups. A repeated-measures analysis of
variance model was used to directly test the outcomes
(depression, mindfulness and rumination) between the
two groups. Statistical significance was set at p<0.05. A
p value of less than or equal to 0.05 was considered
statistically significant.
Zhang et al Dovepress
submit your manuscript | www.dovepress.com
DovePress Neuropsychiatric Disease and Treatment 2019:152698
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
T a b le
1 T h e M B S R In te r v e n ti o n G ro u p S e ss io n D e ta il s
W e e k -T
im e
T h e m e s
C o n te n ts
H o m e w o rk
M a in
P ro
b le m s
S o lu ti o n s
1 -1
A p p ro a c h in g
m in d fu ln e ss
a n d M B S R
1 . In tr o d u c e e a c h o th e r a n d b e c o m e fa m il ia r w it h e a c h o th e r.
2 . S te p in to
a n d c u lt iv a te
m in d fu ln e ss .
3 . In tr o d u c e M B S R a n d th e fo rm
a l te c h n iq u e s.
P ra c ti c e m in d fu ln e ss
b re a th in g e v e r y
d ay .
A b se n t- m in d e d
N e v e r m in d th e d is tr a c ti o n s a t th e
b e g in n in g o f th e p ra c ti c e . L e t it b e .
2 -2
E y e
m in d fu ln e ss
1 . E x p la in
th e c o re
o f o b se r v in g m in d fu ln e ss
a n d te a c h th e
sk il ls to
b e m in d fu ln e ss .
2 . T e a c h h o w
to fo c u s o n o n e ’s m in d o n th e m o m e n t a n d
w it h o u t ju d g e m e n t
P ic k o n e p ic tu re
to o b se r v e w it h
m in d fu ln e ss
a n d re c o rd
y o u r fe e li n g s.
In te rr u p te d
N o ju d g e m e n t a n d n o a n x ie ty . D o y o u r
b e st .
3 -3
E a r
m in d fu ln e ss
1 . E x p la in
th e m e a n in g o f so u n d m in d fu ln e ss .
2 . L e a d th e te a m
fo r h e a ri n g tr a in in g , fe e li n g a ro u n d so u n d
th ro u g h th e w av e s la p p in g , d is ti n g u is h in g so u n d a n d so
o n to
g e t p h y si c a l a n d m e n ta l re la x a ti o n .
3 . A t th e sa m e ti m e , le a rn
h o w
to e x p e ri e n c e th e c h a n g e s
w it h th e so u n d s.
C h o o se
a g e n tl e so n g to
li st e n w it h
m in d fu ln e ss
a n d re c o rd
y o u r fe e li n g s.
S n e a k o ff
T r y in g to
fo c u s y o u r m in d o n th e p re se n t
m o m e n t; if y o u c a n n o t, le t it b e .
4 -4
N o se
m in d fu ln e ss
1 . Il lu st ra te
th e b a si s o f sm
e ll m in d fu ln e ss
a n d le a d te a m
m e m b e rs
to tr a in
th e m
h o w
to u se
th e ir n o se
to fe e l a n d
c o m p re h e n d th e w o rl d .
2 . G u id e te a m
m e m b e rs
to c o m m u n ic a te
a n d d is c u ss
sm e ll
tr a in in g .
C h o o se
o n e k in d o f fr u it a n d sm
e ll
w it h m in d fu ln e ss
a n d re c o rd
y o u r
fe e li n g s.
G iv in g u p
P ra c ti c e m a k e s p e rf e c t.
B e li e v e in
y o u r h e a rt .
5 -5
T o n g u e
m in d fu ln e ss
1 . T e a c h m e m b e rs
h o w
to a p p ly m in d fu ln e ss
to d ri n k in g a n d
e a ti n g .
2 . T a st e m in e ra l w a te r a n d a n a p p le
w it h 7 st e p s: h o ld , lo o k ,
to u c h , sm
e ll , re le a se , sw
a ll o w
a n d fe e l.
M in d fu ln e ss
e a ti n g tr a in in g w it h
ra is in s.
Im a g in e th e fo o d so u rc e a n d th e
p ro c e ss
w h e n e a ti n g a n d re c o rd
y o u r
fe e li n g s.
E m o ti o n a l
in st a b il it y
D o n o t ru sh . S to p w h e n in a b a d st a te . T a k e
a b re a k a n d b ri n g b re a th
to th is m o m e n t
a n d k e e p a p e a c e fu l m in d .
6 -6
B o d y
m in d fu ln e ss
1 . In tr o d u c e b o d y sc a n , w h ic h e n ri c h e s th e c o n te n t o f
p ra c ti c e th ro u g h th e e st a b li sh m e n t o f p h y si c a l a n d
p sy c h o lo g ic a l re sp o n se s to
st re ss
2 . T e a c h a p p ro p ri a te
y o g a -b a se d st re tc h e s, w h ic h in c lu d e
ly in g a n d st a n d in g p o st u re s.
1 . D o b o d y sc a n fr o m
h e a d to
to e .
2 . A c c o rd in g to
o n e ’s o w n a b il it y d o
m in d fu ln e ss
y o g a .
D is tu rb e d b y
tr ifl e s
C h o o se
a se t ti m e to
p ra c ti c e b e fo re
sl e e p .
(C on tin ue d)
Dovepress Zhang et al
Neuropsychiatric Disease and Treatment 2019:15 submit your manuscript | www.dovepress.com
DovePress 2699
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
Results Sociodemographic And Clinical
Characteristics Of Participants The average age of the participants was 18.94 ± 1.31
years, with a range of 17–22 years. Table 2 displays the
characteristics of the two groups.
Efficacy Of MBSR On BDI, MAAS, RRS A repeated-measures analysis of variance model was con-
ducted to examine changes across time between the inter-
vention and comparison conditions on measures of BDI,
MAAS, RRS. Table 3 reveals descriptive statistics with
mean scores of pre-post measures and significance of the
group, time and time-group interactions. The results
revealed a significant interaction between time and condi-
tion for BDI (F=17.721, p<0.001, η2=0.577), MAAS (F=13.489, p<0.001, η2=0.509), and RRS (F=81.566, p<0.001, η2=0.863).
Discussion This study is the first RCT pilot study to apply tailored
mindfulness-based stress reduction to mental health on
subthreshold depression college students to evaluate the
effects of MBSR on their psychological health.
Specifically, the benefits of modified MBSR on partici-
pants have been tested, such as a decrease in depression
and rumination level and an increase in mindfulness state.
Although researchers have been studying subthreshold
depression for decades, subthreshold depression is still
not recognized enough due to the lack of clear and unified
diagnostic criteria, and no authoritative academic institu-
tions have issued clear epidemiological reports.21 There
has been little research on SD in related academic fields in
China.15 Influenced by Chinese cultural values, most peo-
ple are reluctant to seek psychological counselling or
clinical psychotherapy, even if they have clinical symp-
toms that lead to an increase in the prevalence of major
depression in recent years.22 Studies have shown that the
incidence of subthreshold depression among adolescents
has reached 30~40%.23 Although subthreshold depression
does not meet the diagnosis of a clinical depressive epi-
sode, it affects the physical and mental health of indivi-
duals; thus, it is very necessary for early intervention.24
Mindfulness skills have been systematically used in
psychotherapy, and related guidelines have been recom-
mended by NICE for the treatment of depression in the
UK.25 However, for Chinese adolescents, the relatedT a b le
1 (C
o n ti n u e d ).
W e e k -T
im e
T h e m e s
C o n te n ts
H o m e w o rk
M a in
P ro
b le m s
S o lu ti o n s
7 -7
P o si ti v e
th in k in g
1 . In tr o d u c e si tt in g m e d it a ti o n a n d u n d e r th e re se a rc h e rs ’
in st ru c ti o n , te a m
m e m b e rs
h o w
to p ra c ti c e si tt in g
m e d it a ti o n .
2 . P u t fo rw
a rd
sp e c ifi c e v e n ts
a n d a sk
m e m b e rs
h o w to
th in k
a n d h a n d le
th e e v e n ts .
3 . F in d o u t th e p ro b le m s a n d te a c h th e m
h o w
to h a n d le
th in g s in
a m in d fu l w ay .
1 . D o 2 h r si tt in g m e d it a ti o n
2 . T r y to
th in k a b o u t o n e th in g in
y o u r li fe
w it h m in d fu ln e ss
a n d re c o rd
y o u r fe e li n g s in
d e ta il .
1 . T ir e d
2 . C a n n o t
d e te c t
e m o ti o n s
d u ri n g p ra c ti c e
M o d e ra te
p ri n c ip le
to p ra c ti c e y o g a a s
m u c h a s y o u c a n . F o c u s o n th e p ro c e ss , n o t
o n th e o u tc o m e
8 -8
S ta rt
a n e w
m in d fu ln e ss
li fe
1 . D o a su m m a r y o f a ll th e m in d fu ln e ss
sk il ls a n d so lv e
e x is ti n g p ro b le m s.
2 . M e d it a ti o n is a m e a n s to
p o ss e ss
w e ll n e ss
w e re
e m p h a si z e
m in d fu ln e ss .
3 . P ro v id e re la te d re so u rc e s to
fa c il it a te
p a r ti c ip a n ts
fo r
fu rt h e r p ra c ti c e .
E n c o u ra g e a ll p a rt ic ip a n ts
to k e e p
p ra c ti si n g M B S R a n d m in d fu ln e ss
in
th e ir li fe
a n d in
th e fu tu re .
H o w
to
c u lt iv a te
m in d fu ln e ss
in
d a il y li fe
K e e p th e c o re s o f m in d fu ln e ss
in y o u r h e a rt ;
th a t is , fo c u si n g o n th e p re se n t m o m e n t
w it h o u t ju d g e m e n t.
Zhang et al Dovepress
submit your manuscript | www.dovepress.com
DovePress Neuropsychiatric Disease and Treatment 2019:152700
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
systematic and professional psychological counselling was
difficult for them to grasp in a short period of time. In this
study, we designed an eight-week simplified MBSR pro-
gramme according to adolescent characteristics to examine
Table 3 Comparison Of Two Groups On BDI, MASS And RRS
Measure MBSR (n=28) Control Group (n=28) F P Effect Size
(η2) Pre Post 3 Months
Mean(SD)
Pre Post 3 Months
Mean(SD)
BDI 17.00
(2.26)
14.75
(2.14)
13.43
(2.38)
16.75
(2.29)
15.93
(2.42)
16.11
(2.22)
Time effect 44.396 0.00 0.774
Time and group
effect
17.721 0.00 0.577
Group effect 5.764 0.024 0.176
MASS 51.00
(6.04)
54.53
(4.70)
56.96
(5.04)
47.18
(6.72)
47.21
(6.45)
48.96
(5.81)
Time effect 39.080 0.00 0.75
Time and group
effect
13.489 0.00 0.509
Group effect 15.006 0.01 0.357
RRS total score 49.89
(8.23)
44.14
(7.66)
41.35
(7.01)
49.11
(7.31)
48.96
(6.47)
50.04
(6.35)
Time effect 28.277 0.00 0.685
Time and group
effect
81.566 0.00 0.863
Group effect 4.585 0.041 0.145
Table 2 Comparison Of Demographic And Clinical Characteristics Of Two Groups (n=56)
MBSR group (n=28) Control group (n=28) t or χ2 P
Age(mean+SD) 19.14±1.27 18.68±1.30 1.369a 0.182
Grade 2.311b 0.315
Freshman 16 20
Sophomore 10 5
Junior 2 3
Residence 0.350b 0.554
Country 21 19
Rural 7 9
Gender 0.292b 0.589
Female 17 15
Male 11 13
Only-Child or not 1.191b 0.275
Yes 22 25
No 6 3
Notes: aPresent t-test; bPresent χ2 test.
Dovepress Zhang et al
Neuropsychiatric Disease and Treatment 2019:15 submit your manuscript | www.dovepress.com
DovePress 2701
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
its effects on college students with subthreshold depres-
sion. After intervention, the results revealed that the level
of mindfulness in the MBSR group increased with a mean
of (51.00±6.04) points, and the levels of depression
increased with a mean of (54.55±4.70) points. The effect
sizes were significant and lasted for three months.
Compared with traditional MBSR trials, the tailored
MBSR combined mindfulness skills with daily life, and
we summarized the main problems and provided related
solutions during intervention, which were more easily
accepted by students and more easily accepted for mind-
fulness cultivation. Previous studies have reported that
when people engage in 2 hr or 2.5 hr mindfulness training,
it is difficult for them to be clear and focused, and they
always experience problems such as feeling sleepy, tired or
disturbed.26 Thus, in our study, we decreased the training
time and modified the form to establish a tailored MBSR
intervention to ensure feasibility. Through listening, obser-
ving, eating and smelling mindfully, participants could
deal with emotions peacefully and keep a friendly attitude
towards themselves, respecting their own abilities without
judgement or competition. We aim to let participants grasp
basic mindfulness skills through practice and gradually
cultivate mindfulness into their lives. The efficacy of
MBSR on depression level may be related to mindfulness
training. Studies have revealed that mindfulness helps
people avoid the reaction of psychological distress,
which fundamentally improves their perceptions of nega-
tive events and states.27 The core of mindfulness is to
focus on the moment without any judgements.
Mindfulness training helps individuals to consciously
select and recognize thoughts, emotions and feelings but
does not produce habitual reactions, which can enhance
their ability to regulate emotions, thus gradually eliminat-
ing the process of automatic evaluation of negative emo-
tions, which decrease the depression level.28 Increased
responsiveness and activity of the hypothalamic-pituitary-
adrenal (HPA) axis and sympathetic-adrenal-medullary
(SAM) system have been associated with higher levels of
stress, depression and anxiety; studies hypothesize that
mindfulness techniques dampen the hyperactivity of
these systems, which in turns reduces the stress levels.29
This study strengthens the finding of previous studies
that mindfulness is an important mechanism for inhibiting
rumination and preventing symptoms of depression.30
Rumination is a repeated focus on our own way of think-
ing of negative emotions and events that impair psycholo-
gical health.31 The results revealed that adolescents with
subthreshold depression had a high level of rumination.
After 8 weeks of MBSR intervention, the rumination level
decreased significantly, and this effect lasted for 3 months.
Mindfulness is the conscious effort of an individual to
maintain attention in the present moment and makes no
judgement about it.32 Participants in the intervention group
were provided with effective mindfulness skills to reduce
habitual thinking and over-thinking. Through mindfulness
training, our brain’s daily thinking mode changes from
“action mode” to “existence mode”. Action mode is the
inevitable product of the brain’s automatic thinking. When
automatic thinking becomes a habit, our consciousness
will be preoccupied not with the present but with mem-
ories of the past, problems of the present, and anxieties of
the future. The existence mode is a new solution to auto-
matic thinking. It suggests that instead of being trapped in
automatic thinking, subjects should focus their conscious-
ness on the present experience and reduce the focus on
oneself, which is helpful to relax the body and mind.33
Previous studies have shown that mindfulness training
reduced rumination in individuals. Teasdale et al believed
that mindfulness training could relieve cognitive interlock
when rumination takes place.34 That is, when dealing with
stress, individuals will automatically have a non-adaptive
response and pay more attention to the present moment
through mindfulness training, thereby promoting the trans-
fer of attention from rumination.
Strengths & Limitations In our research, we combined mindfulness skills with daily
life based on the characteristics of adolescents, implemen-
ted them in short-term form, considered the feasibility and
scientific nature, and preliminarily applied the tailored
MBSR to adolescents with subthreshold depression in
China. The results showed that the intervention had a
positive effect on their psychological health, including
alleviating symptoms of depression, decreasing rumination
and cultivating mindfulness. The intervention was conve-
nient and had a relatively long effectiveness that lasted for
3 months. Although we use double-blind in the RCT, due
to the limitation of source and conditions, our study was
limited by a modest sample size. Future studies should add
to the sample size to confirm the effects. For future work,
the intervention should be combined with other adjunctive
or complementary and alternative therapies e.g. probiotic
supplementation, which has been shown to alleviate
depressive symptoms.35 Moreover, due to limited time,
the follow-up period of this study was 3 months. In our
Zhang et al Dovepress
submit your manuscript | www.dovepress.com
DovePress Neuropsychiatric Disease and Treatment 2019:152702
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
future study, we will extend the observation time to test
the long-term sustainability of the positive effects.
Conclusions The results from this randomized controlled trial showed
that modified MBSR was effective in cultivating mind-
fulness and reducing depressive symptom levels and rumi-
nation in adolescents with subthreshold depression. This
approach is a simple and feasible intervention that pro-
motes the psychological health of adolescent populations
suffering from subthreshold depression.
Ethical Approval And Consent To Participate The University of Institutional review board approved this
study (No.2017-10) and informed consent was obtained
from every participant.
Consent For Publication Informed consent for the publication of these have been
obtained from all participants. All the students have signed
for agreement. The parent or legal guardian provided
written informed consent for any participant under the
age of 18 years.
Data Sharing Statement The data used to support the findings of this study are
available from the corresponding author upon request.
Acknowledgments The authors were grateful for all the participants in this
study for their cooperation and all the clinical staff for
providing the intervention place and the assistance with
data collection. This work was supported by the grant of
Science Foundation of Ministry of Education of China
[No.17YJCZH241] and the Fundamental Research Funds
for the Provincial Universities [No.2018wld-02]. Jia-Yuan
Zhang and Xiang-Zi Ji are co-first authors.
Disclosure The authors report no conflicts of interest in this work.
References 1. Balazs J, Miklosi M, Kereszteny A, et al. Adolescent subthrehold-
depression and anxiety: psychopathology, functional impairment and increase suicide risk. J Child Psychol Psychiatry. 2013;6:670–677. doi:10.1111/jcpp.12016
2. Tan X, Zhang J, Yang QL. TCM psychological intervention for subthreshold depression and its mechanism. Chin Gen Pract. 2013;6:2649–2651.
3. Keller MB, Klein DN, Hirschfeld RM, et al. Results of the DSM-IV mood disorders field trial. Am J Psychiatry. 1995;152(6):843–849. doi:10.1176/ajp.152.6.843
4. Fergusson DM, Horwood LJ, Ridder EM, et al. Subthreshold depres- sion in adolescence and mental health outcomes in adulthood. Arch Gen Psychiatry. 2005;62(1):66 –72. doi:10.1001/archpsyc.62.1.66
5. Fogel J, Eaton WW, Ford DE. Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up. Acta Psychiatr Scand. 2006;113:36e43. doi:10.1111/j.1600-0447.20 05.00654.x
6. Guberman C, Manassis K. Symptomatology and family functioning in children and adolescents with comorbid anxiety and depression. J Can Acad Child Adolesc Psychiatry. 2011;20:186–195.
7. Eisendrath SJ, Gillung E, Delucchi KL, et al. A randomized con- trolled trial of mindfulness-based cognitive therapy for treatment- resistant depression. Psychother Psychosom. 2016;85:99–110. doi:10. 1159/000442260
8. Kabat-Zinn J. Bringing mindfulness to medicine: an interview with Jon kabat-zinn, PhD. Interview by Karolyn gazelle. Adv Mind Body Med. 2005;21:22–27.
9. MacCoon DG, Imel ZE, Rosenkranz MA, et al. The validation of an active control intervention for mindfulness based stress reduction (MBSR). Behav Res Ther. 2012;50:3–12. doi:10.1016/j.brat.2011.10.011
10. Zhang JY, Zhou YQ, Feng ZW, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) on posttraumatic growth of Chinese breast cancer survivors. Psychol Health Med. 2017;1:94– 109. doi:10.1080/13548506.2016.1146405
11. Alsubaiea M, Abbottb R, Dunn B, et al. Mechanisms of action in mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) in people with physical and/or psychologi- cal conditions: a systematic review. Clin Psychol Rev. 2017;55:74– 91. doi:10.1016/j.cpr.2017.04.008
12. Ng QX, Venkatanarayanan N, Loke W, et al. A meta-analysis of the effectiveness of yoga-based interventions for maternal depression during pregnancy. Complement Ther Clin Pract. 2019;34:8–12. doi:10.1016/j.ctcp.2018.10.016
13. Labelle LE, Campbell TS, Carlson LE. Mindfulness-based stress reduction in oncology: evaluating mindfulness and rumination as mediators of change in depressive symptoms. Mindfulness. 2010;1 (1):28–40. doi:10.1007/s12671-010-0005-6
14. Lazaratou H, Dikeos DG, Anagnostopoulos DC, Soldatos CR. Depressive symptomatology in high school students: the role of age, gender and academic pressure. Community Ment Health J. 2010;46:289–295. doi:10.1007/s10597-010-9296-2
15. Liu AL, Liu XM. Causes of college students subthreshold depression and comprehensive intervention research. J Hubei Normal Univ. 2016;36:107–110.
16. Zainal NZ, Booth S, Huppert FA. The efficacy of mindfulness-based stress reduction on mental health of breast cancer patients: a meta- analysis. Psychol Oncol. 2013;22:1457–1465. doi:10.1002/pon.3171
17. Yang WH, Wu DJ, Peng F. Application of Chinese Version of beck depression inventory-II to Chinese first-year college students. Chin J Clin Psychol. 2012;6:762–764.
18. Brown RA, Ryan RM. Perils and promise in defining and measuring mindfulness: observationsfrom experience. Clin Psychol Sci Pract. 2004;11:242–248. doi:10.1093/clipsy.bph078
19. Deng YQ, Li S, Tang YY, Zhu LH, Richard R, Kirk B. Psychometric properties of the Chinese translation of the Mindful Attention Awareness Scale (MAAS). Mindfulness. 2012;3:10–14. doi:10.1007/ s12671-011-0074-1
20. Han X, Yang HF. Chinese version of Nolen-Hoeksema Ruminative Responses Scale (RRS). Chin J Clin Psychol. 2009; 5:78–92.
Dovepress Zhang et al
Neuropsychiatric Disease and Treatment 2019:15 submit your manuscript | www.dovepress.com
DovePress 2703
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
21. Klein DN, Shankman SA, Lewinsohn PM, Seeley JR. Subthreshold depressive disorder in adolescents: predictorsof escalation to full- syndrome depressive disorders. J Am Acad Child Adolesc Psychiatry. 2009;48:703–710. doi:10.1097/CHI.0b013e3181a56606
22. Ren ZH, Li XY, Zhao LB. The effects of internet cognitive- behavioral therapy on depression and Mechanism. Acta Psychologica Sinica. 2016;48:818–832. doi:10.3724/SP.J.1041.20 16.00818
23. Liu HN, Zeng WX, Li XW, et al. Impacts of attentional training on attention bias of sub-clinical depressed undergraduates. Chin J Behav Med Brain Sc. 2016;25:60–66.
24. Costello DM, Swendsen J, Rose JS, Dierker LC. Risk and protective factors associated with trajectories of depressed mood from adoles- cence to early adulthood. J Consult Clin Psychol. 2008;76:173–183. doi:10.1037/0022-006X.76.2.173
25. Yu QY, Zhang HZ. On analysis of the psychotherapy based on mindfulness meditation. Med Philos. 2013;31:P49–P51.
26. Wu Q, Shi L, Xia ZP, et al. A comparison of intervention effects of three mindfulness training modes on depressed students. Chin J Clin Psychol. 2013;4:685–687.
27. Van Aalderen JR, Donders AR, Giommi F, et al. The efficacy of mind- fulness-based cognitive therapy in recurrent depressed patients with and without a current depressive episode: a randomized controlled trial. Psychol Med. 2012;5:989–1001. doi:10.1017/S0033291711002054
28. Tang HB, Luo HJ, Zhang XL, et al. Mechanism of mindfulness training in the intervention in rumination. Chin J Clin Psychol. 2012;6:451–453.
29. Taren AA, Gianaros PJ, Greco CM, et al. Mindfulness meditation training alters stress-related amygdala resting state functional con- nectivity: a randomized controlled trial. Social Cognit Affective Neurosci. 2015;10(12):1758–1768. doi:10.1093/scan/nsv066
30. Aker M, Harmer C, Landr NI. More rumination and less effective emotion regulation in previously depressed women with preserved executive functions. BMC Psychiatry. 2014;14:334. doi:10.1186/ s12888-014-0334-4
31. Treynor W, Gonzalez R, Nolen-Hoeksema S. Rumination reconsid- ered: a psychometric analysis. Cognit Ther Res. 2003;3:247–259. doi:10.1023/A:1023910315561
32. Bishop SR, Lau M, Shapiro S, et al. Mindfulness: a proposed opera- tional definition. Clin Psychol. 2004;11(3):230–241.
33. Nolen-Hoeksema S, Wisco BE, Lyubomirsky S. Rethinking rumina- tion. Perspective Psychol Sci. 2008;5:400–424. doi:10.1111/j.1745- 6924.2008.00088.x
34. Teasdale JD. Emotional processing, three modes of mind and the prevention of relapse in depression. Behav Res Ther. 1999;S1:53–77. doi:10.1016/S0005-7967(99)00050-9
35. Ng QX, Peters C, Ho CYX, et al. A meta-analysis of the use of probiotics to alleviate depressive symptoms. J Affect Disord. 2018;1 (228):13–19. doi:10.1016/j.jad.2017.11.063
Neuropsychiatric Disease and Treatment Dovepress Publish your work in this journal Neuropsychiatric Disease and Treatment is an international, peer- reviewed journal of clinical therapeutics and pharmacology focusing on concise rapid reporting of clinical or pre-clinical studies on a range of neuropsychiatric and neurological disorders. This journal is indexed on PubMed Central, the ‘PsycINFO’ database and CAS, and
is the official journal of The International Neuropsychiatric Association (INA). The manuscript management system is comple- tely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.dovepress.com/testimo- nials.php to read real quotes from published authors.
Submit your manuscript here: https://www.dovepress.com/neuropsychiatric-disease-and-treatment-journal
Zhang et al Dovepress
submit your manuscript | www.dovepress.com
DovePress Neuropsychiatric Disease and Treatment 2019:152704
N e
u ro
p sy
ch ia
tr ic
D is
e a
se a
n d
T re
a tm
e n
t d
o w
n lo
a d
e d
f ro
m h
tt p
s: //
w w
w .d
o ve
p re
ss .c
o m
/ b
y 7
5 .7
4 .1
8 8
.2 1
1 o
n 1
5 -S
e p
-2 0
2 1
F o
r p
e rs
o n
a l u
se o
n ly
.
Powered by TCPDF (www.tcpdf.org)
