STRESS REDUCTION INTERVENTION RELATED TO WORK ISSUES-Research Paper
Keyli 
ContentServer.asp.pdf
Journal of Psychotherapy Integration Systematic Review of Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction via Group Videoconferencing: Feasibility, Acceptability, Safety, and Efficacy Alesia Moulton-Perkins, Duncan Moulton, Kate Cavanagh, Alex Jozavi, and Clara Strauss Online First Publication, September 14, 2020. http://dx.doi.org/10.1037/int0000216
CITATION Moulton-Perkins, A., Moulton, D., Cavanagh, K., Jozavi, A., & Strauss, C. (2020, September 14). Systematic Review of Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction via Group Videoconferencing: Feasibility, Acceptability, Safety, and Efficacy. Journal of Psychotherapy Integration. Advance online publication. http://dx.doi.org/10.1037/int0000216
Systematic Review of Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction via Group Videoconferencing:
Feasibility, Acceptability, Safety, and Efficacy
Alesia Moulton-Perkins University of Surrey
Duncan Moulton Canterbury Christ Church University
Kate Cavanagh University of Sussex
Alex Jozavi University of Surrey
Clara Strauss University of Sussex and Sussex Partnership NHS Foundation Trust, Hove, East Sussex
Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) are effective in reducing distress among people with physical or mental health problems. However, implementation is limited by variable geo- graphic provision, ability to travel, and the need for remote service delivery during the coronavirus disease 2019 (COVID-19) crisis. Integration with Internet-enabled technologies like videoconferencing potentially enhances access. This article re- ports a systematic review exploring the feasibility, acceptability, safety, and effi- cacy of delivering MBCT/MBSR by videoconferencing (MBCT/MBSR-VC). No restrictions were made about population or study design. Eleven online databases were searched and 10 studies met inclusion criteria. Narrative synthesis was used because of study heterogeneity. Articles featured physical health and nonclinical samples, but not mental health. Three studies had moderate-strong methodological quality. Results supported the feasibility and acceptability of MBCT/MBSR-VC. Considerations of safety were largely unreported. MBCT/MBSR-VC demonstrated medium positive effects on mental health outcomes compared with inactive con- trols (ds � 0.44 –0.71), and little difference compared with active controls like in-person delivery (all confidence intervals crossed zero). Evidence regarding mindfulness or self-compassion as potential mechanisms of action was inconclu- sive. Future implementation research should target mental health populations using noninferiority designs. Adapting MBCT/MBSR to remote delivery will require development of guidelines and training packages to ensure best practice in this medium and adherence to evidence-based MBCT/MBSR models.
Keywords: mindfulness, MBCT, MBSR, videoconferencing, systematic review
Supplemental materials: http://dx.doi.org/10.1037/int0000216.supp
X Alesia Moulton-Perkins, School of Psychology, Univer- sity of Surrey; X Duncan Moulton, Salomons Institute for Ap- plied Psychology, Canterbury Christ Church University; Kate Cavanagh, School of Psychology, University of Sussex; X Alex Jozavi, School of Psychology, University of Surrey; Clara Strauss, School of Psychology, University of Sussex, and Re- search and Development Department, Sussex Partnership NHS Foundation Trust, Hove, East Sussex.
Alex Jozavi is now at the New School of Psychother- apy and Counselling, Middlesex University.
We thank Luit Van Iterson for her assistance with some of the data extraction.
Correspondence concerning this article should be ad- dressed to Clara Strauss, School of Psychology, Univer- sity of Sussex, Pevensey Building, Falmer, Brighton BN1 9QH, United Kingdom. E-mail: c.y.strauss@sussex .ac.uk
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
Journal of Psychotherapy Integration © 2020 American Psychological Association 2020, Vol. 2, No. 999, 000 ISSN: 1053-0479 http://dx.doi.org/10.1037/int0000216
1
Mindfulness is the psychotherapeutic ori- entation predicted to increase the most over the next decade (Norcross, Pfund, & Prochaska, 2013). The most studied mindful- ness-based intervention (MBI; Chiesa, Fazia, Bernardinelli, & Morandi, 2017) is Mindful- ness-Based Stress Reduction (MBSR; Kabat- Zinn, 1990), adapted by Segal, Williams, and Teasdale (2002) for patients with recurrent depression to become Mindfulness-Based Cognitive Therapy (MBCT). MBCT/MBSR is resource-intensive, however, and access is variable (Crane & Kuyken, 2013). Where MBCT/MBSR groups exist, access may be limited by rural location, perceived stigma, caring duties, or mobility difficulties (Schoultz, Macaden, & Hubbard, 2016). Some patients experience access issues be- cause of “transport poverty” (Sustrans, 2012).
MBCT/MBSR has been integrated with on- line delivery methods (Spijkerman, Pots, & Bohlmeijer, 2016). However, changes to the traditional protocols risk reducing efficacy: early evidence suggests that the number of ses- sions and their degree of guidance moderates effect sizes (Spijkerman et al., 2016). Further- more, fewer sessions limits opportunities for between-session mindfulness practice, which is positively related to outcome (Parsons, Crane, Parsons, Fjorback, & Kuyken, 2017).
Improving access to MBIs is challenging, but technologies like videoconferencing (VC) may provide a convenient, cost-effective solution. Most people have Internet access and use it daily (Office for National Statistics, 2018), and there is a public willingness to use video con- sultations with health professionals (NHS Eng- land, 2019). The cancellation of in-person treat- ments because of the coronavirus disease 2019 (COVID-19) crisis attests to the need to review evidence for VC integration.
Reviews of individual interventions by VC attest to its equivalence to in-person treatments: it is as effective (Backhaus et al., 2012; Chakrabarti, 2015; Drago, Winding, & Antypa, 2016), and the therapeutic alliance is preserved (Simpson & Reid, 2014). However, translating traditional 8-week group MBCT/MBSR to re- mote delivery presents unique challenges: ses- sions are long (2–2.5 hr), and as the central medium of effect is the skillful delivery of mindfulness practices and the guided inquiry that follows, synchronous communication with
an experienced mindfulness instructor able to manage group dynamics remotely and technol- ogy is key.
Searches revealed no existing systematic re- views of MBCT/MBSR-VC. Five reviews of digitally delivered MBIs have evaluated diverse technologies; they did not focus solely on MBCT/MBSR (Krolikowski, 2013; Russell, Ugalde, Milne, Austin, & Livingston, 2018; Sevilla-Llewellyn-Jones et al., 2018; Spijker- man et al., 2016; Toivonen, Zernicke, & Carl- son, 2017). All five touched on VC, but none examined issues specific to live VC groups, such as feasibility, acceptability, and safety. Given the 19% yearly increase in mindfulness studies (Chiesa et al., 2017) and rapid develop- ments in VC technology, a systematic review focusing specifically on MBCT/MBSR-VC is timely.
Therefore, this article presents a systematic review of the literature evaluating the feasibil- ity, acceptability, safety, and efficacy of MBCT/ MBSR-VC. Data on mental health outcomes (self-reported anxiety, depression, or distress) will be extracted. Given evidence that mindful- ness significantly mediates the effects of MBIs on mental health outcomes and that self- compassion also plays a role (Gu, Strauss, Bond, & Cavanagh, 2015), data pertaining to both will also be extracted. MBCT, MBSR, and their variants will be included because of their established evidence base.
Aim and Review Questions
This review aimed to describe current evi- dence about the feasibility, acceptability, safety, and efficacy of delivering MBCT/MBSR via group VC. The review questions were:
1. How feasible and acceptable is delivering group MBCT/MBSR-VC?
2. What technical considerations are neces- sary to ensure safe delivery of MBCT/ MBSR-VC?
3. How efficacious is MBCT/MBSR-VC compared with non-VC MBIs and other control conditions (active and inactive) on mental health outcomes and potential mechanisms of action such as mindfulness and self-compassion?
2 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
Method
The review methods were established before its conduct and the protocol registered with PROSPERO, the International Register of Sys- tematic Reviews (CRD42018081724). The scope and methods were adjusted when initial scoping searches revealed the limited nature of the evidence. Reporting followed PRISMA guidelines (Moher, Liberati, Tetzlaff, & Alt- man, 2009).
Design
A mixed methods design was utilized and data extracted from quantitative, qualitative, and mixed methods studies was narratively syn- thesized (Popay et al., 2006).
Inclusion and Exclusion Criteria
Publications featuring adults participating in group MBCT/MBSR or variants delivered by videoconferencing were included. Only English language articles were searched because of re- source limitations. Mindfulness practice and principles had to feature in at least 50% of sessions. Studies of interventions not explicitly based on MBCT/MBSR were excluded. Groups could consist of participants attending remotely, or mixed remote and in-person attendance. The location of the facilitator was not stipulated. Initial scoping searches revealed a modest body of literature and, therefore, no limit was made concerning population, setting, or design.
Search Strategy
Electronic searches of the peer reviewed and gray literature were conducted by the first au- thor (Alesia Moulton-Perkins) using a combina- tion of free text and MeSH headings to find synonyms of the terms MBCT, MBSR, mind- ful�, and videoconferencing in title and abstract (see Online Supplemental Materials Resource 1). Databases searched were: Web of Science (CORE Collection including conference pro- ceedings), SCOPUS, PubMed, BNI, CINAHL, EMBASE, HBE, HMIC, PsycINFO, MED- LINE, and AMED. Searches were conducted on 27.03.2018 and then updated on 19.04.2019. In the interim the HBE database had ceased to be available through HDAS and, therefore, only articles to 27.03.2018 were included from this
database. A final search was conducted on 23. 11.2019. Publications from 1998 were included as this was the year when the first guidelines were published on videoconferencing (Ameri- can Psychiatric Association, 1998). The Inter- national Trials Registry Platform was checked for studies registered between 2017 and 2019 but none met inclusion criteria. Reference lists from published articles were also consulted. Where reported data was incomplete, study au- thors were contacted. Two authors responded, one of whom provided sufficient further data to calculate effect sizes.
Procedure
Records identified through database search- ing were independently double screened on title and abstract by two authors (Alesia Moulton- Perkins and Alex Jozavi). Full text articles were obtained and independently assessed for eligi- bility by Alesia Moulton-Perkins and Alex Jo- zavi. Data was extracted using a tailormade form (see Online Supplemental Materials Re- source 2) by a member of the research team and checked by another (Alesia Moulton-Perkins or Duncan Moulton). Data pertaining to effect size calculations and quality appraisal was indepen- dently extracted and completed in duplicate by Alesia Moulton-Perkins and Duncan Moulton. Where disagreements arose, these were re- solved through discussion with reference to a third party (Clara Strauss and Kate Cavanagh).
Analytic Strategy
Data on populations, interventions, compara- tors, outcome, and the review questions were extracted, tabulated, and narratively synthesized to draw conclusions about the similarities and differences across studies. Where indices were unreported, these were calculated where possi- ble. Feasibility was operationalized as the pro- portion of those approached who responded, were eligible, consented, and who were study completers (provided a complete dataset). Indi- ces were calculated from the whole sample where a study was controlled and from the VC intervention where it was not. Acceptability was analyzed according to intervention completer rate (participants completing at least 50% of the intervention) and patient satisfaction. Safety in- dices were extracted using guidelines for deliv-
3SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
ery of VC mental health services (Luxton, Siro- tin, & Mishkind, 2010).
The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quanti- tative studies (Thomas, Ciliska, Dobbins, & Mi- cucci, 2004) was used to appraise the method- ological quality of the included studies, a tool deemed reliable (Armijo-Olivo, Stiles, Hagen, Biondo, & Cummings, 2012). Two raters inde- pendently completed the table and any discrep- ancies were resolved to arrive at an agreed overall rating of “strong,” “moderate,” or “weak” for each article.
Outcomes pertaining to mental health (dis- tress, anxiety, or depression), and potential mechanisms of action (mindfulness, self- compassion) were extracted. Mindfulness and self-compassion were considered potential mechanisms of action if they were shown to be impacted positively by the mindfulness inter- vention. No formal mediation analysis was con- ducted. Effectiveness was assessed by extract- ing relevant author-reported results showing statistically significant postintervention group differences in controlled studies or prepost im- provement in uncontrolled studies. Where there were no significant differences, true null find- ings were not assumed unless studies used a noninferiority or equivalence study design.
In addition, individual study means, standard deviations, and Ns were extracted and the Stan- dardized Mean Difference (SMD) calculated separately for active controlled and inactive- controlled studies. Effect size d was calculated as the mean difference in postintervention scores between groups, divided by the pooled postintervention SD, using an online calculator (Lenhard & Lenhard, 2016). Effect size was interpreted as small, medium or large (d � 0.2, 0.5, or 0.8, respectively) according to Cohen’s (1969) convention. Control conditions were cat- egorized as active or inactive using the Co- chrane handbook criteria (Higgins et al., 2019). To interpret nonsignificant effect sizes, 95% confidence intervals (CIs) were inspected. Where CIs crossed zero but were highly skewed around zero the possibility of lack of statistical power was considered. Because CIs represent not just a means of null hypothesis significance testing, but a “range of plausible values for the true effect” (Finch, Cumming, & Thomason, 2001, p. 204), CIs with a markedly asymmetric spread around zero were noted as evidence to-
ward a possible effect requiring further re- search.
Finally, a “vote counting” approach (Thomas, O’Mara-Eves, Kneale, & Shemilt, 2017) was applied to results as a “descriptive tool” to summarize effectiveness across the two methods. Results were narratively synthesized in light of the quality appraisal using a positive deviance (Bradley et al., 2009) approach: stud- ies with the best outcomes were identified and compared with those with the worst outcomes and shared features noted.
Results
In total, 1,716 records were identified through database searching, and another nine through hand searches of reference lists (see Online Supplemental Materials Resource 3 for PRISMA diagram). After screening title and abstract and removing redundant records, 22 articles were assessed for eligibility on full text. Ten were excluded because they were not based on MBCT/MBSR or did not feature group vid- eoconferencing (see Online Supplemental Ma- terials Resource 4 for full details of articles excluded). Twelve articles representing 10 em- pirical studies were selected for the review.
Study Characteristics
Selected characteristics of the included stud- ies are summarized in Table 1. Publication dates ranged from 2008 to 2019, with most 2014 or later. Included studies featured a total of 789 participants (median � 66.5). The majority fo- cused on physical health populations, with the remainder covering nonclinical populations such as universities and the corporate sector. None targeted mental health populations.
Participants’ mean ages ranged from 30 to 73. Most participants were female (range � 47– 88%), although three studies did not report age and gender. None reported socioeconomic status, rural or urban residence, or transport poverty status. Regions represented were North America (N � 4), Australasia (N � 2), and Europe (N � 3), including one in the United Kingdom.
Comparators were utilized in the majority of studies: eight were controlled, of which four were randomised controlled trials (RCTs). Two studies compared MBCT/
4 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
T ab
le 1
S el
ec te
d C
h a ra
ct er
is ti
cs o f
In cl
u d ed
S tu
d ie
s
O ut
co m
es :
B et
w ee
n- gr
ou p
(w it
h in
-g ro
u p )
S tu
dy D
es ig
n P
op ul
at io
n V
C in
te rv
en ti
on C
om pa
ra to
r
P os
it iv
e di
ff er
en ce
fa vo
rs V
C (p
� .0
5) (i
m p ro
ve m
en t)
N o
di ff
er en
ce (p
� .0
5)
N eg
at iv
e di
ff er
en ce
fa vo
rs co
nt ro
l (p
� .0
5) (d
et er
io ra
ti o n )
A ik
en s
et al
. (2
01 4)
R C
T U
.S .
M B
S R
-V C
In ac
ti ve
co nt
ro l:
W L
C P
S S
F F
M Q
(n on
ju dg
e) —
C or
po ra
te em
pl oy
ee s
N �
44 N
� 45
F F
M Q
ob se
rv e
de sc
ri be
aw ar
e no
nr ea
ct B
og os
ia n
et al
. (2
01 5)
R C
T U
.K .
M B
C T
-V C
In ac
ti ve
co nt
ro l:
W L
C G
H Q
H A
D S
-A —
M ul
ti pl
e sc
le ro
si s
N �
19 (F
� 47
% )
N �
21 (F
� 62
% )
H A
D S
-D
M a g e
53 M
a g e
51 C
av al
er a
et al
. (2
01 9)
R C
T It
al y
M B
S R
-V C
A ct
iv e
no n-
M B
I co
nt ro
l: S
el f-
gu id
ed on
li ne
ps yc
ho ed
H A
D S
-D —
—
M ul
ti pl
e sc
le ro
si s
N �
54 (F
� 67
% )
N �
67 (F
� 62
% )
H A
D S
-A
M a g e
42 M
a g e
43 F
ar ve
r- V
es te
rg aa
rd et
al .
(2 01
8) P
re -p
os t
m ix
ed m
et ho
ds
D en
m ar
k C
O P
D M
B C
T -V
C —
— H
A D
s- to
t —
N �
8 (F
� 50
% )
M a g e 73
G ar
dn er
-N ix
et al
. (2
00 8)
Q ua
si -E
xp C
an ad
a ch
ro ni
c pa
in
M B
S R
-V C
A ct
iv e
co nt
ro l:
M B
S R
-F 2F
— S
F -3
6- M
C S
—
N �
57 (F
� 88
% )
N �
99 (F
� 80
% )
M a g e
54 M
a g e
51 In
ac ti
ve co
nt ro
l: W
L C
S F
-3 6-
M C
S —
— N
� 57
(F �
75 %
) M
a g e
52 G
ar dn
er -N
ix et
al .
(2 01
4) Q
ua si
-E xp
C an
ad a
ch ro
ni c
pa in
M B
S R
m ix
ed F
2F an
d V
C N
� 60
In ac
ti ve
co nt
ro l:
W L
C N
� 59
S F
-3 6-
M C
S —
—
(t a b le
co n ti
n u es
)
5SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
T ab
le 1
(c o n ti
n u ed
)
O ut
co m
es :
B et
w ee
n- gr
ou p
(w it
h in
-g ro
u p )
S tu
dy D
es ig
n P
op ul
at io
n V
C in
te rv
en ti
on C
om pa
ra to
r
P os
it iv
e di
ff er
en ce
fa vo
rs V
C (p
� .0
5) (i
m p ro
ve m
en t)
N o
di ff
er en
ce (p
� .0
5)
N eg
at iv
e di
ff er
en ce
fa vo
rs co
nt ro
l (p
� .0
5) (d
et er
io ra
ti o n )
Jo ha
ns so
n et
al .
(2 01
5) Q
ua si
-E xp
M ix
ed m
et ho
ds
S w
ed en
M B
S R
-V C
A ct
iv e
co nt
ro l:
M B
S R
-F 2F
— S
C S
—
Jo ha
ns so
n an
d B
ju hr
(2 01
6) T
B I
N �
13 (F
� 85
% )
N �
12 (F
� 92
% )
C P
R S
-D
M a g e
46 M
a g e
48 C
P R
S -A
In ac
ti ve
co nt
ro l:
W al
ki ng
gr ou
p —
S C
S —
N �
9 (F
� 67
% )
C P
R S
-D M
a g e
51 C
P R
S -A
K rä
ge lo
h et
al .
(2 01
9) P
re -p
os t
N ew
Z ea
la nd
U ni
ve rs
it y
st ud
en ts
an d
st af
f
M B
S R
/M B
C T
- V
C N
/A B
D I
B A
I —
N �
32 (F
� 66
% )
P A
N A
S -N
P A
N A
S -P
M a g e
30 S C
S F
F M
Q (a
w a re
d es
cr ib
e n o n re
a ct
o b se
rv e)
F F
M Q
(t o ta
l n o n ju
d g e)
S im
m on
s an
d R
ed m
an (2
01 8)
Q ua
si -E
xp A
us tr
al ia
U ni
ve rs
it y
st ud
en ts
M B
S R
/M B
C T
- V
C A
ct iv
e co
nt ro
l: S
el f-
gu id
ed M
B I
— M
A A
S —
N �
19 a
N �
52 a
Z er
ni ck
e et
al .
(2 01
4, 20
16 )
R C
T C
an ad
a ca
nc er
M B
S R
-V C
In ac
ti ve
co nt
ro l:
W L
C P
O M
S F
F M
Q (o
bs er
ve de
sc ri
be no
nj ud
ge no
nr ea
ct )
—
N �
30 (F
� 73
% )
N �
32 (F
� 72
% )
C S
O S
I
M a g e
58 M
a g e
58 F
F M
Q (a
w ar
e)
N o te
. U
nc on
tr ol
le d
st ud
ie s
in it
al ic
s. B
A I
� B
ec k
A nx
ie ty
In ve
nt or
y; B
D I-
II �
B ec
k D
ep re
ss io
n In
ve nt
or y-
II ;
C S
O S
I �
C al
ga ry
S ym
pt om
s of
S tr
es s
In ve
nt or
y; C
P R
S -A
, D
� C
om pr
eh en
si ve
P sy
ch op
at ho
lo gi
ca l
R at
in gs
S ca
le -A
nx ie
ty ,
D ep
re ss
io n;
F �
fe m
al e;
F 2F
� fa
ce to
fa ce
; F
F M
Q �
F iv
e F
ac et
M in
df ul
ne ss
Q ue
st io
nn ai
re ;
G H
Q �
G en
er al
H ea
lt h
Q ue
st io
nn ai
re ;
H A
D s-
A ,
D ,
T ot
� H
os pi
ta l
A nx
ie ty
an d
D ep
re ss
io n
S ca
le -A
nx ie
ty ,
D ep
re ss
io n,
T ot
al ;
M A
A S
� M
in df
ul ne
ss A
tt en
ti on
A w
ar en
es s
S ca
le ;
M B
I �
M in
df ul
ne ss
- B
as ed
In te
rv en
ti on
; P
A N
A S
-P ,
A �
P os
it iv
e an
d N
eg at
iv e
A ff
ec t
S ca
le -P
os it
iv e,
N eg
at iv
e; P
O M
S �
P ro
fi le
of M
oo d
S ta
te s;
P S
S �
P er
ce iv
ed S
tr es
s S
ca le
; Q
ua si
-E xp
� Q
ua si
-e xp
er im
en t;
S C
S -S
F �
S el
f- C
om pa
ss io
n S
ca le
-S ho
rt F
or m
; S
F 36
-M C
S �
S ho
rt F
or m
-3 6
- M
en ta
l C
om po
ne nt
S co
re ;
V C
� V
id eo
co nf
er en
ce .
a F
ig ur
es no
t gi
ve n
by au
th or
s an
d, th
er ef
or e,
w er
e ca
lc ul
at ed
fr om
pr op
or ti
on s
re po
rt ed
.
6 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
MBSR-VC to the same face-to-face (F2F) intervention. Two featured active control con- ditions (self-guided online MBI � 1; non- MBI � 1) and 6 inactive control conditions (Wait List Control [WLC] � 5; walking group � 1). Two studies featured both active and inactive controls.
Authors generally reported positive out- comes, with no statistically significant negative or adverse effects found. Of the seven compar- isons of VC to non-MBI control (inactive or active), six reported statistically significant be- tween-groups differences in favor of VC on at least some of the outcomes. The three studies comparing VC with a mindfulness control found no significant differences between groups, whether that was self-guided, or F2F. However, given none were designed to test non- inferiority effects, we cannot assume this im- plies equivalence. Evidence regarding potential mechanisms of action (mindfulness or self- compassion) was inconclusive. For mindful- ness, when VC was compared with a non-MBI control the results were contradictory: Zernicke et al. (2014) found no significant difference in four of the five FFMQ (Five Factor Mindfulness Questionnaire) subscales, whereas Aikens et al. (2014) found all but one significant. Given that Zernicke et al. (2014) was rated strong method- ologically, greater confidence can be taken in their results. Self-compassion was measured in two studies: Johansson, Bjuhr, Karlsson, Karlsson, and Rönnbäck (2015) found no sig- nificant difference between VC and F2F MBSR or a walking group, while Krägeloh et al. (2019) found a difference favoring VC.
Intervention characteristics are described in Table 2. Six studies were based on MBSR, two MBCT and two mixed MBCT/MBSR. Three studies adhered to the original manual in terms of intervention length (Farver-Vestergaard et al., 2018; Johansson et al., 2015; Zernicke et al., 2014), the latter two featuring an online retreat. MBCT/MBSR often include a 1-day retreat dur- ing the 8-week course to give participants op- portunity to deepen their mindfulness practice. Scant details were given about the online retreat other than stating it was held for a full day, and in the Johansson et al. (2015) qualitative eval- uation that participants enjoyed it. Details re- garding treatment integrity were also largely absent. Only Bogosian et al. (2015) monitored treatment integrity through listening to tapes in
supervision. None of the studies used standard- ized tools such as the MBI:TAC (Mindfulness- Based Interventions: Teaching Assessment Cri- teria; Crane et al., 2013). Reporting of mindfulness practice, intended or actual, was incomplete or omitted in most cases, with only two studies reporting sufficient data to allow total recommended practice minutes to be cal- culated. Group sizes ranged from four to 22. Studies featuring the largest groups all followed a model whereby participants met as an in- person group while the facilitator joined re- motely (N � 3). Study authors did not comment on how participants experienced these varying methods of delivery. Four studies failed to re- port group size.
Feasibility and Acceptability
Feasibility results are presented in Table 3. Zernicke and colleagues (2014) were unique in reporting feasibility as their primary outcome measure, with a priori criteria. They met their targets in all indices except study completion (missed by 2%). Only two studies reported suf- ficient data to be able to calculate the majority of feasibility indices, making inferences diffi- cult to draw. Differences in study design and recruitment strategy led to large variations in response rates (10 to 75%). Eligibility rates followed a similar pattern, with recruitment strategies designed to achieve a more represen- tative sample generally experiencing lower rates (e.g., Zernicke et al., 2014: 37%) than those studies drawing from a more selective, and arguably less representative pool of partic- ipants (e.g., Krägeloh et al., 2019: 99%). Con- sent rates varied from 17 to 93%, although this variation is probably best explained by differ- ences in recruitment strategies and reporting. Finally, the rate of study completion (partici- pants completing postintervention measures) ranged from 27 to 100%. Overall, however, study completion rates were high, with only three studies reporting rates below 75%.
Acceptability results are shown in Table 3. Intervention completion rates (participants re- ceiving at least half the intervention) could not be calculated in four studies; the remaining six ranged from 67 to 100%. Four studies included formal participant satisfaction measures and one reported informal participant comments. Two studies reported participant satisfaction
7SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
T ab
le 2
M in
d fu
ln es
s b y
V C
In te
rv en
ti o n
C h a ra
ct er
is ti
cs
M B
I in
te rv
en ti
on T
ec hn
ol og
y L
oc at
io n
S tu
dy M
od el
G ro
up fo
rm at
H ar
dw ar
e an
d so
ft w
ar e
T ec
hn ic
al pr
ob le
m s
an d
su pp
or t
P ar
ti ci
pa nt
s an
d fa
ci li
ta to
r
A ik
en s
et al
. (2
01 4)
M B
S R
7 �
60 m
in R
ec om
m en
de d
to ta
l pr
ac ti
ce :
In se
ss io
n: 42
0 m
in ,
ho m
e: 64
8 m
in (a
ct ua
l 72
0)
C om
pa ny
co nf
er en
ce ro
om w
it h
w eb
in ar
br oa
dc as
t sc
re en
N ot
re po
rt ed
P ar
ti ci
pa nt
s: M
ix ed
F 2F
/V C
V C
so ft
w ar
e no
t st
at ed
F ac
il it
at or
: U
nc le
ar A
ss um
ed cl
in ic
al ly
un su
pe rv
is ed
lo ca
ti on
B og
os ia
n et
al .
(2 01
5) M
B C
T 8
� 60
m in
W eb
ca m
s an
d he
ad se
t pr
ov id
ed P
ro bl
em s:
S om
e pa
rt ic
ip an
ts ci
te d
te ch
ni ca
l pr
ob le
m s,
fo r
ex am
pl e,
co m
pu te
r vi
ru s,
st ol
en co
m pu
te r,
pr ob
le m
s w
it h
au di
o
P ar
ti ci
pa nt
s an
d fa
ci li
ta to
r: A
ll se
pa ra
te re
m ot
e lo
ca ti
on s
G ro
up si
ze m
ax 5
S ky
pe A
ss um
ed cl
in ic
al ly
un su
pe rv
is ed
lo ca
ti on
R ec
om m
en de
d to
ta l
pr ac
ti ce
: In
se ss
io n:
12 0–
16 0
m in
ho m
e: 42
0– 94
0 m
in C
av al
er a
et al
. (2
01 9)
M B
S R
8 se
ss io
ns ,
le ng
th no
t re
po rt
ed P
er so
na l
P C
P ro
bl em
s: A
ve ra
ge on
e lo
st co
nn ec
ti on
pe r
se ss
io n
bu t
di d
no t
si gn
ifi ca
nt ly
im pa
ct on
gr ou
p ac
ti vi
ti es
or di
sc us
si on
s
P ar
ti ci
pa nt
s an
d fa
ci li
ta to
r: A
ll se
pa ra
te ho
m e-
ba se
d lo
ca ti
on s
A ve
ra ge
gr ou
p si
ze 5
S ky
pe C
li ni
ca ll
y un
su pe
rv is
ed lo
ca ti
on F
ar ve
r- V
es te
rg aa
rd et
al .
(2 01
8) M
B C
T 8
� 12
0 m
in V
C -e
na bl
ed to
uc h
sc re
en co
m pu
te r
S up
po rt
: 1:
1 pr
eg ro
up or
ie nt
at io
n P
ar ti
ci pa
nt s
an d
fa ci
li ta
to r:
A ll
se pa
ra te
ho m
e- ba
se d
lo ca
ti on
s G
ro up
si ze
4 E
W II
T el
ec ar
e P
ro bl
em s:
C on
ne ct
io n
is su
es m
en ti
on ed
bu t
no t
cl ar
ifi ed
ho w
fr eq
ue nt
th ey
w er
e.
C li
ni ca
ll y
un su
pe rv
is ed
lo ca
ti on
R ec
om m
en de
d to
ta l
ho m
e pr
ac ti
ce :
98 0
m in
G ar
dn er
-N ix
et al
. (2
00 8)
M B
S R
10 �
12 0
m in
H os
pi ta
l- ba
se d
V C
ha rd
w ar
e N
ot re
po rt
ed P
ar ti
ci pa
nt s:
M ix
ed F
2F /V
C G
ro up
si ze
10 –2
0 O
nt ar
io T
el em
ed ic
in e
F ac
il it
at or
: R
em ot
e 38
4 kb
it /s
A ss
um ed
cl in
ic al
ly su
pe rv
is ed
lo ca
ti on
G ar
dn er
-N ix
et al
. (2
01 4)
M B
S R
12 se
ss io
ns ,
le ng
th no
t re
po rt
ed H
os pi
ta l-
ba se
d V
C ha
rd w
ar e
N ot
re po
rt ed
P ar
ti ci
pa nt
s: M
ix ed
F 2F
/V C
G ro
up si
ze 12
–2 2
O nt
ar io
T el
em ed
ic in
e N
et w
or k
F ac
il it
at or
: R
em ot
e R
ec om
m en
de d
to ta
l in
se ss
io n
pr ac
ti ce
: 14
5 m
in A
ss um
ed cl
in ic
al ly
su pe
rv is
ed lo
ca ti
on Jo
ha ns
so n
et al
. (2
01 5)
M B
S R
8 �
15 0
m in
� 1
da y
re tr
ea t
A do
be C
on ne
ct N
ot re
po rt
ed P
ar ti
ci pa
nt s
an d
fa ci
li ta
to r:
A ll
se pa
ra te
re m
ot e
lo ca
ti on
s (t
a b le
co n ti
n u es
)
8 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
T ab
le 2
(c o n ti
n u ed
)
M B
I in
te rv
en ti
on T
ec hn
ol og
y L
oc at
io n
S tu
dy M
od el
G ro
up fo
rm at
H ar
dw ar
e an
d so
ft w
ar e
T ec
hn ic
al pr
ob le
m s
an d
su pp
or t
P ar
ti ci
pa nt
s an
d fa
ci li
ta to
r
Jo ha
ns so
n an
d B
ju hr
(2 01
6) A
ct ua
l ho
m e
pr ac
ti ce
: 1,
19 7
m in
A ss
um ed
cl in
ic al
ly un
su pe
rv is
ed lo
ca ti
on K
rä ge
lo h
et al
. (2
01 9)
M B
S R
/M B
C T
6 �
90 –1
10 m
in C
ol le
ge -b
as ed
co nf
er en
ce ro
om S
up po
rt :
R es
ea rc
he r
an d
ad di
ti on
al cl
in ic
al ps
yc ho
lo gi
st pr
es en
t in
pe rs
on at
al l
se ss
io ns
P ar
ti ci
pa nt
s: F
2F (s
es si
on 1
F 2F
) G
oT oM
ee ti
ng F
ac il
it at
or :
S ep
ar at
e re
m ot
e lo
ca ti
on G
ro up
si ze
15 –1
7 C
li ni
ca ll
y su
pe rv
is ed
lo ca
ti on
R ec
om m
en de
d to
ta l
ho m
e pr
ac ti
ce :
45 0
m in
(a ct
ua l
17 5
m in
) S
im m
on s
an d
R ed
m an
(2 01
8) M
B S
R /M
B C
T 4
� 90
m in
A do
be C
on ne
ct S
up po
rt :
O nl
in e
fo ru
m P
ro bl
em s:
S om
e pa
rt ic
ip an
ts di
d no
t ha
ve m
ic ro
ph on
es an
d th
is li
m it
ed di
sc us
si on
N ot
re po
rt ed
A ss
um ed
cl in
ic al
ly un
su pe
rv is
ed lo
ca ti
on
Z er
ni ck
e et
al .
(2 01
4, 20
16 )
M B
S R
8 �
12 0
m in
se ss
io ns
� 6
hr re
tr ea
t W
eb ca
m s
an d
he ad
se t
pr ov
id ed
S up
po rt
: 1:
1 pr
eg ro
up or
ie nt
at io
n �
co nt
in uo
us li
ve te
ch ni
ca l
su pp
or t
P ar
ti ci
pa nt
s an
d fa
ci li
ta to
r al
l se
pa ra
te re
m ot
e lo
ca ti
on s
G ro
up si
ze 4–
11 eM
in df
ul A
ss um
ed cl
in ic
al ly
un su
pe rv
is ed
lo ca
ti on
R ec
om m
en de
d to
ta l
ho m
e pr
ac ti
ce :
2, 20
5 m
in (a
ct ua
l 10
50 m
in )
9SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
T ab
le 3
F ea
si b il
it y
a n d
A cc
ep ta
b il
it y
F ea
si bi
li ty
ra te
s A
cc ep
ta bi
li ty
S tu
dy R
es po
ns e
E li
gi bi
li ty
C on
se nt
S tu
dy co
m pl
et io
n In
te rv
en ti
on co
m pl
et er
s P
ar ti
ci pa
nt sa
ti sf
ac ti
on
A ik
en s
et al
. (2
01 4)
23 %
U na
bl e
to ca
lc ul
at e
U na
bl e
to ca
lc ul
at e
87 %
77 %
A ve
ra ge
sa ti
sf ac
ti on
ra ti
ng s
87 %
B og
os ia
n et
al .
(2 01
5) 70
% 46
% 93
% 90
% 95
% N
ot re
po rt
ed C
av al
er a
et al
. (2
01 9)
U na
bl e
to ca
lc ul
at e
73 %
58 %
98 %
U na
bl e
to ca
lc ul
at e
N ot
fo rm
al ly
co ll
ec te
d bu
t sp
on ta
ne ou
s po
si ti
ve co
m m
en ts
. S
om e
or ga
ni ze
d F
2F gr
ou p
af te
r co
ur se
. F
ar ve
r- V
es te
rg aa
rd et
al .
(2 01
8) U
na bl
e to
ca lc
ul at
e U
na bl
e to
ca lc
ul at
e 17
% 10
0% 10
0% P
os it
iv e
co m
m en
ts :
R ed
uc ed
tr av
el .
M ix
ed co
m m
en ts
on w
he th
er re
la ti
ng w
as en
ha nc
ed or
de cr
ea se
d. T
he ra
pe ut
ic re
la ti
on sh
ip :
S co
re s
si m
il ar
F 2F
an d
V C
. G
ar dn
er -N
ix et
al .
(2 00
8) U
na bl
e to
ca lc
ul at
e U
na bl
e to
ca lc
ul at
e 77
% 51
% U
na bl
e to
ca lc
ul at
e N
ot re
po rt
ed
G ar
dn er
-N ix
et al
. (2
01 4)
U na
bl e
to ca
lc ul
at e
U na
bl e
to ca
lc ul
at e
97 %
U na
bl e
to ca
lc ul
at e
68 %
N ot
re po
rt ed
Jo ha
ns so
n et
al .
(2 01
5) Jo
ha ns
so n
an d
B ju
hr (2
01 6)
75 %
U na
bl e
to ca
lc ul
at e
75 %
89 %
U na
bl e
to ca
lc ul
at e
M os
t sa
ti sfi
ed .
S om
e re
fu se
d al
lo ca
ti on
to V
C be
ca us
e th
ey di
d no
t w
an t
to at
te nd
an in
te rn
et gr
ou p
or co
ul d
no t
us e
co m
pu te
r fo
r lo
ng pe
ri od
s. A
ll re
m ai
ne d
aw ak
e de
sp it
e m
en ta
l fa
ti gu
e. K
rä ge
lo h
et al
. (2
01 9)
U na
bl e
to ca
lc ul
at e
99 %
21 %
52 %
67 %
N ot
re po
rt ed
S im
m on
s an
d R
ed m
an (2
01 8)
U na
bl e
to ca
lc ul
at e
U na
bl e
to ca
lc ul
at e
44 %
27 %
U na
bl e
to ca
lc ul
at e
S at
is fa
ct io
n fo
r th
e V
C gr
ou p
ag gr
eg at
ed w
it h
th e
se lf
-g ui
de d
gr ou
p so
un ab
le to
as se
ss .
Z er
ni ck
e et
al .
(2 01
4) 10
% 37
% 93
% 82
% 83
% 10
0% sa
ti sfi
ed ,
49 %
m et
51 %
ex ce
ed ed
ex pe
ct at
io ns
; 98
% re
co m
m en
d it
to ot
he rs
10 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
rates, with most recommending it to others and 75–100% remarking it was beneficial or met their expectations. Two studies specifically probed satisfaction with VC in their question- naire wording, with only Farver-Vestergaard et al. (2018) complementing this quantitative data with a thematic analysis. Two themes were rel- evant to VC: “Practical aspects of attendance” and “Relating.” Positive experiences included attending from home and reduced travel. For example, one participant said, “I have been glad that it is home-based. Otherwise I wouldn’t have been able to participate” (p. 472). Some also felt the online nature of the group enhanced relating to others as it demanded more intense management of group dynamics, with one par- ticipant saying “Well the upside of using the tele-monitor . . . were that if someone raised their hand they got to say something. And it was not like the same people talked all the time, which is often the case on courses like these (p. 472).” Negative relational impacts of VC were focused on technical difficulties. Some partici- pants felt this created a barrier to feeling safe enough to disclose personal experiences and feelings.
Safety
VC-specific safety issues were underreported (see Online Supplemental Materials Resource 5). Preliminary planning was better reported than other safety indices like emergency plan- ning, adverse events, deterioration or data secu- rity, and privacy issues. About a third of studies provided precourse technical instruction, per- sonal equipment, or featured clinic-based VC systems. Three did not report whether equip- ment was provided and one stipulated that par- ticipants should provide their own. At least two studies took place in “clinically unsupervised” (Luxton et al., 2010) locations, without direct access to clinical support (see also Table 2); four further studies did not explicitly state the location of participants. Krägeloh et al. (2019) reported that participants had in-person access to a clinical psychologist and Gardner-Nix, Backman, Barbati, and Grummitt (2008, 2014) used a telemedicine link from participants’ local hospitals. Of the six locations known or as- sumed to have been clinically unsupervised, only two reported providing ongoing technical support. None of the studies mentioned VC-
specific good practice guidelines or facilitator training in conducting psychological interven- tions online. Of these technological details, the most comprehensively reported was VC plat- form (see Table 2), with all but one study nam- ing it. Few studies reported on frequency of technical problems, with only one quantifying it (Cavalera et al., 2019). Technical support was provided in four studies, although only Zernicke et al. (2014) indicated it was continuous and live.
None of the studies reported emergency plans for supporting remote participants. Adverse events such as technical barriers to participation were cited in three studies. Farver-Vestergaard et al. (2018) reported that one participant sug- gested the provision of a hotline to contain worries at the end of the session or in the event of technical failure. This was also the only study to mention a significant deterioration in one of their participants. Data security and privacy is- sues were almost entirely unaddressed: only Zernicke et al. (2014) described procedures to ensure that only approved group members could attend.
Study Quality
Study quality was rated using Thomas and colleagues’ (2004) EHPP tool (see Online Sup- plemental Materials Resource 6 for quality table and breakdown of ratings). Two of the RCTs were rated as “Strong” and one as “Moderate.” All other studies were rated as “Weak.” Selec- tion bias regarding recruitment method and lack of randomized controls compromised study quality in most cases.
Efficacy
A meta-analysis of study outcomes was not conducted because of study heterogeneity. Be- tween-groups postintervention effect sizes for the three studies with active controls (see Table 4) were statistically nonsignificant (95% CIs crossing zero) for all outcomes except the de- pression subscale of the Hospital Anxiety and Depression Scale (HADs), where Cavalera et al.’s (2019) MBSR-VC was superior to a self- guided non-MBI psychoeducation intervention with a small effect (d � 0.40). Neither of the studies comparing VC to F2F found statistically significant differences. These findings cannot be regarded as conclusive as in most cases the 95%
11SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
CIs crossed zero asymmetrically in favor of the VC group, which could indicate lack of statis- tical power. Given that none of the included studies conducted noninferiority comparisons between MBCT/MBSR-VC and non-VC MBIs, we have not analyzed them separately from comparisons with active controls.
Of the four studies with inactive comparators (see Table 5) all found small to medium, or medium effect size differences (d � 0.44 –0.71) favoring VC on most distress measures, al- though not on the HADs anxiety subscale and the General Health Questionnaire in Bogosian et al.’s (2015) study. Results evidencing mind- fulness as a potential mechanism of action were contradictory: Aikens et al. (2014) found a large effect on the FFMQ observe subscale and me- dium effects on the rest, while for Zernicke et al. (2014) confidence intervals for all subscales of the FFMQ crossed zero, suggesting no im- pact of the VC-MBI on this hypothesized mech- anism of action. The evidence for self- compassion outcomes was also inconclusive: although confidence intervals on self-compas- sion crossed zero when VC was compared with F2F MBSR or a walking group by Johansson et al. (2015), the sample size was very small and, therefore, should be interpreted with caution.
Discussion
This review aimed to describe the current evidence for the feasibility, acceptability, safety, and efficacy of MBCT/MBSR-VC. We identified 10 studies, including five new studies not found in previous reviews. MBCT/ MBSR-VC appears effective for reducing psy- chological distress compared with inactive con- trols, with medium effect sizes evidenced. Effectiveness compared with active controls was less clear however, as were any effects on potential mechanisms of action. No studies were sufficiently powered to conduct noninfe- riority analyses comparing MBCT/MBSR-VC to in-person treatment. Drawing firm conclu- sions about feasibility and acceptability was hampered by lack of reporting and general low study quality. However, in the three studies that were of strong/moderate quality, results were promising, with high participant satisfaction and intervention completion rates. We were un- able to draw conclusions about safety as few studies reported on adverse events or data secu-T
ab le
4 M
en ta
l H
ea lt
h O
u tc
o m
es a n d
P o te
n ti
a l
M ec
h a n is
m s
o f
A ct
io n
fo r
F a ce
to F
a ce
M B
C T
/M B
S R
a n d
A ct
iv e-
C o n tr
o l
C o n d it
io n s
V C
in te
rv en
ti on
N on
-M B
I co
nt ro
l S
M D
F ac
e to
fa ce
M B
C T
/M B
S R
co nt
ro l
S M
D
S tu
dy D
es ig
n M
ea su
re P
re M
(S D
) P
re N P
os t
M (S
D )
P os
t N
P re
M (S
D )
P re N
P os
t M
(S D
) P
os t
N d
95 %
C I
P re
M (S
D )
N P
os t
M (S
D )
N d
95 %
C I
C av
al er
a et
al .
(2 01
9) R
C T
H A
D S
A 7.
94 (4
.2 2)
69 6.
19 (3
.5 3)
69 6.
84 (3
.4 1)
70 6.
80 (3
.8 3)
70 0.
17 [�
0. 17
,0 .5
0] —
— —
— —
— H
A D
S D
4. 69
(3 .4
7) 69
3. 64
(2 .9
1) 69
4. 66
(3 .2
4) 70
4. 92
(3 .5
2) 70
0. 40
[0 .0
6, 0.
73 ]
— —
— —
— —
G ar
dn er
-N ix
et al
. (2
00 8)
Q ua
si -E
xp S F
3 6
M C
S 34
.3 (1
2. 6)
57 38
.5 (1
2. 9)
40 —
— —
— —
— 34
.8 (1
3. 2)
99 38
.7 (1
3. 2)
50 0.
02 [�
0. 40
,0 .4
3] Jo
ha ns
so n
et al
. (2
01 5)
Q ua
si -E
xp C
P R
S -D
6. 6
(2 .7
) 16
5. 2
(2 .6
) 13
— —
— —
— —
8. 3
(3 .5
) 12
7. 4
(4 .9
) 12
0. 57
[� 0.
23 ,1
.3 7]
C P
R S
-A 8.
2 (2
.3 )
16 6.
0 (2
.6 )
13 —
— —
— —
— 8.
2 (3
.8 )
12 7.
1 (4
.4 )
12 0.
31 [�
0. 48
,1 .1
0] S C
S 36
.8 (7
.1 )
16 39
.9 (7
.0 )
13 —
— —
— —
— 36
.2 (1
1. 6)
12 40
.3 (1
1. 1)
12 0.
04 [�
0. 74
,0 .8
3]
N o te
. M
ea su
re s
in it
al ic
s hi
gh er
sc or
e �
le ss
di st
re ss
/d is
ab il
it y.
A ll
m ea
su re
s po
si ti
ve d
fa vo
rs in
te rv
en ti
on (e
xc ep
t S
C S
). S
M D
ca lc
ul at
ed po
st in
te rv
en ti
on be
tw ee
n- gr
ou ps
; C
P R
S -D
, A
� C
om pr
eh en
si ve
P sy
ch op
at ho
lo gi
ca l
R at
in g
S ca
le ,
D ep
re ss
io n,
A nx
ie ty
; H
A D
S -A
, D
� H
os pi
ta l
A nx
ie ty
an d
D ep
re ss
io n
S ca
le ,
A nx
ie ty
, D
ep re
ss io
n; Q
ua si
-E xp
� Q
ua si
-e xp
er im
en t;
S C
S �
S el
f- C
om pa
ss io
n S
ca le
; S
F 36
M C
S �
S ho
rt F
or m
36 M
en ta
l C
om po
ne nt
S co
re ;
S M
D �
S ta
nd ar
di ze
d M
ea n
D if
fe re
nc e;
C I
� co
nfi de
nc e
in te
rv al
.
12 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
T ab
le 5
M en
ta l
H ea
lt h
O u tc
o m
es a n d
P o te
n ti
a l
M ec
h a n is
m s
o f
A ct
io n
fo r
In a ct
iv e
C o n tr
o l
C o n d it
io n s
V C
in te
rv en
ti on
C on
tr ol
S M
D
S tu
dy D
es ig
n M
ea su
re P
re M
(S D
) P
re N
P os
t M
(S D
) P
os t
N P
re M
(S D
) P
re N
P os
t M
(S D
) P
os t
N d
95 %
C I
A ik
en s
et al
. (2
01 4)
R C
T P
S S
24 .4
6 (6
.2 9)
44 18
.0 0
(7 .0
1) 44
24 .7
6 (8
.1 6)
45 23
.3 2
(8 .4
5) 45
0. 69
[0 .2
6, 1.
11 ]
F F
M Q
a w
a 24
.1 1
(5 .0
1) 44
27 .6
7 (5
.3 3)
44 23
.9 6
(6 .1
4) 45
24 .2
9 (6
.3 5)
45 �
0. 58
[� 1.
00 ,�
0. 15
] F
F M
Q o b s
23 .2
5 (5
.5 4)
44 28
.8 1
(5 .4
4) 44
24 .2
2 (5
.4 6)
45 23
.9 1
(5 .9
0) 45
� 0.
86 [�
1. 30
,� 0.
43 ]
F F
M Q
d es
26 .4
3 (4
.7 3)
44 28
.7 2
(6 .1
5) 44
25 .2
9 (5
.7 2)
45 25
.4 8
(4 .7
9) 45
� 0.
59 [�
1. 01
,� 0.
16 ]
F F
M Q
n re
a 21
.1 4
(4 .1
4) 44
24 .1
7 (4
.5 1)
44 21
.3 1
(4 .5
2) 45
21 .4
3 (4
.1 0)
45 �
0. 64
[� 1.
06 ,�
0. 21
] F
F M
Q n ju
d 28
.5 0
(6 .1
4) 44
30 .3
3 (5
.8 9)
44 27
.1 3
(5 .4
0) 45
27 .9
8 (5
.8 6)
45 �
0. 40
[� 0.
82 ,0
.0 2]
B og
os ia
n et
al .(
20 15
) R
C T
G H
Q 16
.1 0
(6 .3
5) 19
11 .4
3 (4
.5 5)
17 17
.2 9
(4 .8
9) 21
14 .8
7 (5
.9 4)
19 0.
65 [�
0. 03
,1 .3
2] H
A D
S -A
6. 96
(3 .7
2) 19
5. 48
(2 .7
5) 17
6. 98
(3 .1
1) 21
6. 58
(3 .4
2) 19
0. 35
[� 0.
31 ,1
.0 1]
H A
D S
-D 6.
24 (3
.5 1)
19 5.
12 (3
.2 0)
17 7.
20 (3
.3 5)
21 7.
63 (3
.9 6)
19 0.
69 [0
.0 2,
1. 37
] G
ar dn
er -N
ix et
al .(
20 08
) Q
ua si
-E xp
S F
3 6
M C
S 34
.3 (1
2. 6)
57 38
.5 (1
2. 9)
40 33
.2 (1
1. 6)
59 33
.2 (1
1. 6)
53 �
0. 44
[� 0.
85 ,�
0. 02
] Jo
ha ns
so n
et al
. (2
01 5)
Q ua
si -E
xp C
P R
S -D
6. 6
(2 .7
) 16
5. 2
(2 .6
) 13
6. 9
(2 .9
) 10
6. 9
(2 .9
) 9
0. 62
[� 0.
2, 1.
49 ]
C P
R S
-A 8.
2 (2
.3 )
16 6.
0 (2
.6 )
13 5.
9 (2
.8 )
10 4.
5 (2
.8 )
9 �
0. 56
[� 1.
43 ,0
.3 1]
S C
S 36
.8 (7
.1 )
16 39
.9 (7
.0 )
13 36
.0 (1
1. 8)
10 38
.6 (1
0. 0)
9 �
0. 16
[� 1.
01 ,0
.7 0]
Z er
ni ck
e et
al .(
20 14
) R
C T
P O
M S
37 .4
3 (3
5. 69
) 30
17 .1
6 (3
0. 72
) 30
42 .1
6 (2
7. 40
) 32
35 .6
9 (3
1. 52
) 32
0. 60
[0 .0
9, 1.
10 ]
C S
O S
I 59
.7 0
(3 2.
52 )
30 36
.8 3
(2 1.
87 )
30 66
.1 0
(3 3.
77 )
32 58
.7 2
(3 7.
38 )
32 0.
71 [0
.2 0,
1. 22
] F
F M
Q a w
a 27
.1 7
(7 .6
7) 30
30 .2
1 (5
.0 0)
30 27
.7 8
(6 .0
5) 32
27 .8
0 (5
.6 4)
32 �
0. 45
[� 0.
96 ,0
.0 5]
F F
M Q
o b s
24 .5
3 (6
.2 9)
30 26
.2 9
(5 .0
2) 30
24 .8
8 (7
.2 3)
32 26
.3 4
(6 .0
6) 32
0. 01
[� 0.
49 ,0
.5 1]
F F
M Q
d es
26 .1
7 (6
.2 0)
30 28
.1 3
(6 .0
3) 30
23 .8
1 (7
.2 8)
32 25
.5 3
(6 .7
3) 32
� 0.
41 [�
0. 91
,0 .1
0] F
F M
Q n re
a 19
.7 3
(4 .6
8) 30
22 .1
3 (3
.7 1)
30 18
.7 5
(4 .0
7) 32
20 .8
4 (4
.8 1)
32 �
0. 30
[� 0.
80 ,0
.2 0]
F F
M Q
n ju
d 26
.6 3
(7 .0
6) 30
29 .5
0 (5
.6 8)
30 28
.0 3
(7 .1
2) 32
28 .8
4 (5
.8 6)
32 �
0. 11
[� 0.
61 ,0
.3 8]
N o te
. C
P R
S -D
, A
� C
om pr
eh en
si ve
P sy
ch op
at ho
lo gi
ca l
R at
in g
S ca
le ,
D ep
re ss
io n,
A nx
ie ty
; H
A D
S -A
, D
� H
os pi
ta l
A nx
ie ty
an d
D ep
re ss
io n
S ca
le ,
A nx
ie ty
, D
ep re
ss io
n; Q
ua si
-E xp
� Q
ua si
-e xp
er im
en t;
S C
S �
S el
f- C
om pa
ss io
n S
ca le
; S
F 36
M C
S �
S ho
rt F
or m
36 M
en ta
l C
om po
ne nt
S co
re ;
S M
D �
S ta
nd ar
di ze
d M
ea n
D if
fe re
nc e;
C I
� co
nfi de
nc e
in te
rv al
; R
C T
� ra
nd om
is ed
co nt
ro ll
ed tr
ia ls
; P
S S
� P
er ce
iv ed
S tr
es s
S ca
le ;
F F
M Q
� F
iv e
F ac
et M
in df
ul ne
ss Q
ue st
io nn
ai re
; G
H Q
� G
en er
al H
ea lt
h Q
ue st
io nn
ai re
; P
O M
S �
P ro
fi le
of M
oo d
S ta
te s;
C S
O S
I �
C al
ga ry
S ym
pt om
s of
S tr
es s
In ve
nt or
y.
13SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
rity-privacy issues. Nevertheless, we believe the preliminary evidence for MBCT/MBSR-VC ef- fectiveness recommends it as a remote alterna- tive for people currently denied in-person treat- ment by the COVID-19 crisis.
Characteristics of Included Studies
We found that physical health conditions among a largely female population were most frequently studied, echoing other mindfulness studies (Bodenlos, Strang, Gray-Bauer, Faherty, & Ashdown, 2017). The most common inter- vention was MBSR, followed by adapted com- bined MBCT/MBSR, and the least common tra- ditional MBCT. This is perhaps not surprising given MBSR was originally developed to help people cope with illness and pain. However, there is clear gap in the literature for VC deliv- ery in mental health settings. Reporting of ad- herence and treatment integrity was largely ab- sent.
None of the studies featured an average age below 30. This profile challenges assumptions about digital interventions suiting a young adult demographic and suggests that age may not be a barrier to health care technology (Banbury, Nancarrow, Dart, Gray, & Parkinson, 2018). We were unable to clarify participants’ urban or rural location or transport poverty status. High income countries were overrepresented, al- though digital technologies are increasingly be- ing recognized as a key to addressing the mental health needs of low- and middle-income coun- tries (Naslund et al., 2017).
Feasibility and Acceptability
Given variable reporting of feasibility indi- ces, study completion rates were the clearest indicator of feasibility of MBCT/MBSR-VC as they were calculable for all but one study. The only study to set a priori benchmarks was Zer- nicke et al. (2014). Using their 85% study com- pletion rate target as a guide, it is promising that five of the nine studies reporting sufficient data met the target, with a sixth missing by a small margin. Using a positive deviance approach to identify characteristics of the highest perform- ers, we found all had interventions of at least eight sessions and smaller group sizes. Perhaps surprisingly, in all five studies the facilitator and all participants were in separate places, in con-
trast to the mixed nature of groups in other studies.
Given few studies specifically probed VC- specific participant satisfaction and nearly half failed to report intervention completer rates, only tentative conclusions can be made about acceptability. The data that is reported suggests good satisfaction and intervention completion. Where dissatisfaction occurred, it was generally connected to technical difficulties. These results reflect those of Banbury et al. (2018), who found that patients in nearly all studies valued being able to attend the group from home and otherwise would not have been able to partici- pate.
Qualitative data was scant with only one study giving a rich picture of participants’ ex- periences of MBCT/MBSR-VC (Farver-Vester- gaard et al., 2018). None of the studies probed how participants found meditating in front of a screen. The extent to which technical issues like distortions in sound quality impacted on this experience is also unknown.
Safety
Safety reporting was markedly absent. None of the studies described facilitators being trained in VC groups or referred to practice guidelines. This is concerning, considering the first guidelines on delivering mental health ser- vices by VC were published 10 years before the oldest study in our review (American Psychiat- ric Association, 1998). While none of the stud- ies involved a mental health population, facili- tators may be ill-equipped to manage sessions safely without proper training and guidance, not least situations of lost connections and people becoming distressed or feeling abandoned (Luxton et al., 2010).
Reporting of adverse events was rare, but only three studies appeared even to collect this data. Managing risk at a distance in a group VC setting was largely unexplored. Sansom-Daly, Wakefield, McGill, and Patterson (2015) em- phasize the importance of developing safety protocols and links with local services when working with distressed patients at a distance. Privacy concerns were not raised by participants in any of the studies, although it is not clear whether this was because researchers failed to ask, or participants were genuinely uncon- cerned. Banbury et al.’s (2018) systematic re-
14 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
view of home-based VC support groups showed few patients were concerned about others seeing into their homes. Because of limited reporting, few conclusions can be drawn about the tech- nical aspects of safe MBCT/MBSR-VC deliv- ery. We do not know how frequent technical difficulties were, typical bandwidths, levels of technical support, or the impact of facilitator and participant location. A third of studies failed to describe the equipment used, the group size, or other potentially important factors im- pacting call quality and, therefore, participant experience. For MBI-VC provision in response to COVID-19, we recommend usual risk proce- dures for F2F groups combined with facilitators having appropriate digital competencies (Pote et al., 2020).
Efficacy
The evidence for efficacy of MBCT/ MBSR-VC is limited by the small number of studies and their inconsistent quality. The stron- gest evidence came from the four waitlist- controlled studies, in which five of the seven subscales measuring mental health outcomes showed statistically significant medium effect sizes favoring MBCT/MBSR-VC. Three of these effects were found in the two higher qual- ity studies (Bogosian et al., 2015; Zernicke et al., 2014), increasing the confidence we can have in these results. Nevertheless, it should be noted that the three studies measuring anxiety failed to find statistically significant effects, echoing a meta-analysis which found effects of MBIs for depression but not for anxiety (Strauss, Cavanagh, Oliver, & Pettman, 2014).
Regarding active controls, there were no sta- tistically significant differences found in studies comparing VC to face-to-face mindfulness groups. A small significant effect on depression was found when MBCT/MBSR-VC was com- pared with self-guided psychoeducation (Caval- era et al., 2019). However, only further research using robustly powered noninferiority designs will be able to establish this definitively.
The two studies reporting mindfulness out- comes found contradictory results: Aikens et al. (2014) found significant differences between VC and control, whereas Zernicke et al. (2014) did not. Author-reported prepost intervention results for the majority of mindfulness sub- scales were nonsignificant. This mirrors the het-
erogeneity found in the literature. Visted, Vøll- estad, Nielsen, and Nielsen’s (2015) systematic review found a small effect of MBIs on mind- fulness compared with a WLC. However, this obscured the fact that seven studies supported it and nine did not. Also, in a meta-analysis of mediation studies of MBCT and MBSR, Gu et al. (2015) found moderate but consistent evi- dence supporting mindfulness as a mediator of clinical outcomes.
Self-compassion featured in two studies in- cluded in our review. In the one controlled study (Johansson et al., 2015) there was no difference between the three groups (VC, F2F, and walking) on author-reported significance testing or SMDs calculated here. Gu et al.’s (2015) meta-analysis identified only three stud- ies measuring self-compassion, just one sup- porting compassion as a mediator. None of our included studies conducted mediation analyses involving mindfulness or self-compassion out- comes and, therefore, no conclusions regarding mechanisms of action can be drawn.
In summary, the evidence found in the pres- ent study lends tentative support to the efficacy of delivering mindfulness by VC. There was no evidence of deterioration and there were prom- ising signs that VC groups may prove not to be inferior to traditional F2F MBCT/MBSR. Given that few studies were randomized or of moder- ate or strong methodological quality, our con- clusions must be tentative. Given the lack of common measures of mindfulness or self- compassion, no conclusions about proposed mechanisms of action can be drawn.
Strengths and Limitations
This is the first review to focus on MBCT/ MBSR by VC. Although the limited and heter- ogenous evidence base precluded meta-analy- sis, methods used for conducting this narrative synthesis were rigorous. Following good prac- tice recommendations for systematic reviews (Karlsson & Bergmark, 2015) we separately extracted SMDs for the WLC and active con- trols. We applied a robust, flexible quality ap- praisal tool (Armijo-Olivo et al., 2012) allowing appraisal of a range of quantitative designs. However, this meant the strengths of the qual- itative analysis in Farver-Vestergaard et al.’s (2018) mixed methods study were not recog- nized in the quality appraisal.
15SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
We were unable to aggregate data and instead extracted individual study SMDs within a nar- rative synthesis. Narrative synthesis, and vote counting particularly have been criticized for lacking transparency and introducing bias (Val- entine et al., 2017). However, when used as an initial description of patterns across studies, vote-counting has defenders (Popay et al., 2006). In the present review vote-counting was not used in isolation and conclusions were tri- angulated with the extraction of SMDs, which control for differing sample sizes. It has been argued that narrative synthesis is a realistic and useful method when limited evidence is avail- able, provided the aims of the review are ad- justed and the claims made tentative (Thomas et al., 2017).
Further Research
Clearly MBCT/MBSR-VC groups are under- researched. We were limited in our ability to draw conclusions regarding implementation. Only two studies compared videoconference- delivered mindfulness to the same dose of face- to-face mindfulness and neither measured ad- herence. Future implementation research should investigate the comparability of the two modes of delivery using a noninferiority randomized controlled design. This should be informed by implementation science theoretical frameworks, such as the patient and provider barriers and facilitators to health care access presented by O’Connor et al.’s (2016) digital model. Further- more, intention to treat analyses should be used, something rarely or even incorrectly used by study authors in the present review. Gold stan- dard treatments should be used as only one study in the present review featured full MBSR (Johansson et al., 2015) and none used classic MBCT. Given that MBCT is an evidence-based treatment for recurrent depression, there is a clear imperative for studying its delivery by VC for this population.
As yet the cost effectiveness of implementing MBCT/MBSR-VC is unknown. The need for technical support and potential need to provide equipment to participants to ensure social inclu- sion and equality may mean savings are re- duced. Before services seek to implement MBCT/MBSR-VC, a full economic evaluation should be conducted to ensure financial viabil- ity.
Future research should follow telehealth re- search reporting guidelines (Abel, Glover, Brandt, & Godleski, 2017) and study technolo- gy-specific aspects of VC mindfulness to better understand factors influencing engagement and effectiveness (Russell et al., 2018). This may include software and hardware used, Internet bandwidth, location of participants and facilita- tor and rural or urban setting. The needs of older clients should be considered, as age-related cog- nitive and sensory functioning changes may im- pact telemedicine engagement (Stronge, Rog- ers, & Fisk, 2007). It is concerning that the present studies paid so little attention to the equipment used. Future trials should consult a diverse range of service users regarding opti- mum equipment. Equipment should be offered, as Farver-Vestergaard et al. (2018) did, to pro- mote social inclusion and equality of access.
Given the importance of minimizing barriers to participants’ mindfulness practice and group communication, trouble-free connections are essential. Facilitators should not provide live support during calls, as this distracts from sup- porting others. Banbury et al. (2018) describe how good technical support can significantly ease participants’ anxiety. This will be espe- cially important as researchers begin to work with mental health populations.
A better understanding of how cohesion in groups influences the effectiveness of VC group therapy is needed. Some evidence suggests VC group interactions may remain superficial be- cause of participants’ difficulty trusting each other (Kozlowski & Holmes, 2014). Measures such as the Group Therapy Alliance Scale (Pin- sof & Catherall, 1986) would differentiate alli- ance to group and to leader.
Process variables such as therapeutic alliance and group cohesion may be influenced by VC telepresence. Bouchard, Robillard, Marchand, Renaud, and Riva (2007) found the feeling of presence predicted the strength of the therapeu- tic alliance over a course of CBT for panic disorder. Better image and sound quality may promote greater presence (Lozano et al., 2015) and, therefore, the choice of VC platform and the Internet connection quality will be impor- tant to consider carefully in future studies. Sim- ilarly, training programs for online mindfulness instructors should be developed based on good practice guidelines to meet the challenges of managing group dynamics remotely. An
16 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
adapted form of the MBI-TAC (Crane et al., 2013) could be developed from the practice of innovatory programs (e.g., Meissner, 2017; Sansom, Crane, Karunavira Koerbel, & Yiangou, 2020) to assess adherence and teacher competency when delivering MBSR/MBCT by VC. Recent calls for a digitally trained mental health workforce (Foley & Woollard, 2019) make this need clear.
The potential for harm was not addressed in the majority of included studies, yet literature suggests this is present across all populations, even in F2F settings (Baer, Crane, Miller, & Kuyken, 2019). Safety should be a key consid- eration when working via VC with clinically unsupervised participants calling in from home. Risk management protocols for VC, like those produced by professional bodies such as the American Psychological Association (2013) need to be urgently developed and evaluated so that potential risks can be mitigated (e.g., clients with suicidal risk having preestablished written instructions for seeking help). Safety planning should be prioritized in any future trial, consid- ering technology-specific issues in risk assess- ment and emergency planning.
In conclusion, this review has provided an important overview of the work conducted thus far on delivering MBCT/MBSR via VC. Al- though the evidence provides preliminary sup- port for the feasibility, acceptability, and effi- cacy of disseminating MBCR/MBSR by VC, it has also highlighted significant gaps in our knowledge in all these domains, not least safety and the long term effects of MBSR/MBCT-VC. Given drivers such as the United Kingdom Mindfulness All-Party Parliamentary Group’s (2015) recommendation that the provision of MBCT be radically upscaled, the growing call from patients for convenient digital options (Seres, 2015), and the prediction that online clinics will soon be the norm (Fairburn & Patel, 2017), the need to develop a robust base of evidence and clinical policy is clear and urgent.
References
Abel, E. A., Glover, J., Brandt, C. A., & Godleski, L. (2017). Recommendations for the reporting of Telemental Health (TMH) literature based on a systematic review of Clinical Video Teleconfer- encing (CVT) and depression. Journal of Technol-
ogy in Behavioral Science, 2, 28– 40. http://dx.doi .org/10.1007/s41347-016-0003-1
Aikens, K. A., Astin, J., Pelletier, K. R., Levanovich, K., Baase, C. M., Park, Y. Y., & Bodnar, C. M. (2014). Mindfulness goes to work: Impact of an online workplace intervention. Journal of Occupa- tional and Environmental Medicine, 56, 721–731. http://dx.doi.org/10.1097/JOM.00000000000 00209
American Psychiatric Association. (1998). Telepsy- chiatry via videoconferencing resource document. Washington, DC: Author.
American Psychological Association. (2013). Guide- lines for the practice of telepsychology. Retrieved from https://www.apa.org/practice/guidelines/ telepsychology
Armijo-Olivo, S., Stiles, C. R., Hagen, N. A., Biondo, P. D., & Cummings, G. G. (2012). As- sessment of study quality for systematic reviews: A comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Prac- tice Project Quality Assessment Tool: Method- ological research. Journal of Evaluation in Clini- cal Practice, 18, 12–18. http://dx.doi.org/10.1111/ j.1365-2753.2010.01516.x
Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., . . . Thorp, S. R. (2012). Videoconferencing psychotherapy: A systematic review. Telehealth, Telepsychology, and Technol- ogy, 9, 111–131. http://dx.doi.org/10.1037/ a0027924
Baer, R., Crane, C., Miller, E., & Kuyken, W. (2019). Doing no harm in mindfulness-based programs: Conceptual issues and empirical findings. Clinical Psychology Review, 71, 101–114. https://psycnet. apa.org/doi/10.1016/j.cpr.2019.01.001
Banbury, A., Nancarrow, S., Dart, J., Gray, L., & Parkinson, L. (2018). Telehealth interventions de- livering home-based support group videoconfer- encing: Systematic review. Journal of Medical In- ternet Research, 20, e25. http://dx.doi.org/10 .2196/jmir.8090
Bodenlos, J. S., Strang, K., Gray-Bauer, R., Faherty, A., & Ashdown, B. K. (2017). Male representation in randomized clinical trials of mindfulness-based therapies. Mindfulness, 8, 259–265. http://dx.doi .org/10.1007/s12671-016-0646-1
Bogosian, A., Chadwick, P., Windgassen, S., Norton, S., McCrone, P., Mosweu, I., . . . Moss-Morris, R. (2015). Distress improves after mindfulness train- ing for progressive MS: A pilot randomised trial. Multiple Sclerosis Journal, 21, 1184–1194. http:// dx.doi.org/10.1177/1352458515576261
Bouchard, S., Robillard, G., Marchand, A., Renaud, P., & Riva, G. (2007, October 25–27). Presence and the bond between patients and their psycho- therapists in the cognitive-behavior therapy of panic disorder with agoraphobia delivered in vid-
17SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
eoconference. Paper presented at the Proceedings of the 10th Annual International Workshop on Presence, Barcelona. Retrieved from https://bit.ly/ 2Qeudg3
Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009). Research in action: Using positive deviance to improve quality of health care. Implementation Science, 4, 25. http://dx.doi.org/10.1186/1748- 5908-4-25
Cavalera, C., Rovaris, M., Mendozzi, L., Pugnetti, L., Garegnani, M., Castelnuovo, G., . . . Pagnini, F. (2019). Online meditation training for people with multiple sclerosis: A randomized controlled trial. Multiple Sclerosis Journal, 25, 610– 617. http://dx .doi.org/10.1177/1352458518761187
Chakrabarti, S. (2015). Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches. World Journal of Psychiatry, 5, 286– 304. http://dx.doi.org/10.5498/wjp.v5.i3.286
Chiesa, A., Fazia, T., Bernardinelli, L., & Morandi, G. (2017). Citation patterns and trends of system- atic reviews about mindfulness. Complementary Therapies in Clinical Practice, 28, 26–37. http:// dx.doi.org/10.1016/j.ctcp.2017.04.006
Cohen, J. (1969). Statistical power analysis for the behavioral sciences. New York, NY: Academic Press.
Crane, R. S., Eames, C., Kuyken, W., Hastings, R. P., Williams, J. M. G., Bartley, T., . . . Surawy, C. (2013). Development and validation of the mind- fulness-based interventions - teaching assessment criteria (MBI:TAC). Assessment, 20, 681– 688. http://dx.doi.org/10.1177/1073191113490790
Crane, R. S., & Kuyken, W. (2013). The implemen- tation of Mindfulness-Based Cognitive Therapy: Learning from the U. K. health service experience. Mindfulness, 4, 246–254. http://dx.doi.org/10 .1007/s12671-012-0121-6
Drago, A., Winding, T. N., & Antypa, N. (2016). Videoconferencing in psychiatry, a meta-analysis of assessment and treatment. European Psychiatry, 36, 29–37. http://dx.doi.org/10.1016/j.eurpsy.2016 .03.007
Fairburn, C. G., & Patel, V. (2017). The impact of digital technology on psychological treatments and their dissemination. Behaviour Research and Therapy, 88, 19–25. http://dx.doi.org/10.1016/j .brat.2016.08.012
Farver-Vestergaard, I., O’Connor, M., Smith, N. C., Løkke, A., Bendstrup, E., & Zachariae, R. (2018). Tele-delivered mindfulness-based cognitive ther- apy in chronic obstructive pulmonary disease: A mixed-methods feasibility study. Journal of Tele- medicine and Telecare, 25, 468– 475. http://dx.doi .org/10.1177/1357633X18780563
Finch, S., Cumming, G., & Thomason, N. (2001). Reporting of statistical inference in the Journal of
Applied Psychology: Little evidence of reform. Educational and Psychological Measurement, 61, 181–210. http://dx.doi.org/10.1177/0013164012 1971167
Foley, T., & Woollard, J. (2019). Digital future of mental healthcare and its workforce: A report on a mental health stakeholder engagement to inform the Topol Review. Leeds, England: Health Educa- tion England. Retrieved from https://topol.hee.nhs .uk/wp-content/uploads/HEE-Topol-Review-Mental- health-paper.pdf
Gardner-Nix, J., Backman, S., Barbati, J., & Grum- mitt, J. (2008). Evaluating distance education of a mindfulness-based meditation programme for chronic pain management. Journal of Telemedi- cine and Telecare, 14, 88–92. http://dx.doi.org/10 .1258/jtt.2007.070811
Gardner-Nix, J., Barbati, J., Grummitt, J., Pukal, S., & Newton, R. R. (2014). Exploring the effective- ness of a mindfulness-based chronic pain manage- ment course delivered simultaneously to on-site and off-site patients using telemedicine. Mindful- ness, 5, 223–231. http://dx.doi.org/10.1007/ s12671-012-0169-3
Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve men- tal health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical Psy- chology Review, 37, 1–12. http://dx.doi.org/10 .1016/j.cpr.2015.01.006
Higgins, J. P. T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M. J., & Welch, V. A. (2019). Cochrane handbook for systematic reviews of in- terventions version 6.0 (updated August 2019). Retrieved from www.training.cochrane.org/ handbook
Johansson, B., & Bjuhr, H. (2016). Teaching Mind- fulness-Based Stress Reduction (MBSR) live on- line to individuals suffering from mental fatigue - A qualitative evaluation. International Journal of Social Science Studies, 4. http://dx.doi.org/10 .11114/ijsss.v4i3.1389
Johansson, B., Bjuhr, H., Karlsson, M., Karlsson, J. O., & Rönnbäck, L. (2015). Mindfulness-Based Stress Reduction (MBSR) delivered live on the internet to individuals suffering from mental fa- tigue after an acquired brain injury. Mindfulness, 6, 1356–1365. http://dx.doi.org/10.1007/s12671-015- 0406-7
Kabat-Zinn, J. (1990). Full catastrophe living: How to cope with stress, pain and illness using mind- fulness meditation. New York, NY: Dell Publish- ing.
Karlsson, P., & Bergmark, A. (2015). Compared with what? An analysis of control-group types in Co- chrane and Campbell reviews of psychosocial treatment efficacy with substance use disorders.
18 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
Addiction, 110, 420– 428. http://dx.doi.org/10 .1111/add.12799
Kozlowski, K. A., & Holmes, C. M. (2014). Experi- ences in online process groups: A qualitative study. Journal for Specialists in Group Work, 39, 276–300. http://dx.doi.org/10.1080/01933922 .2014.948235
Krägeloh, C. U., Medvedev, O. N., Taylor, T., Wrap- son, W., Rix, G., Sumich, A., . . . Siegert, R. J. (2019). A pilot randomized controlled trial for a videoconference-delivered mindfulness-based group intervention in a nonclinical setting. Mind- fulness, 10, 700–711. http://dx.doi.org/10.1007/ s12671-018-1024-y
Krolikowski, A. M. (2013). The effectiveness of in- ternet-based mindfulness interventions for physi- cal and mental illnesses: A narrative review. Inter- national Journal of Cyber Behavior, Psychology and Learning, 3, 84–96. http://dx.doi.org/10.4018/ ijcbpl.2013100106
Lenhard, W., & Lenhard, A. (2016). Calculation of effect sizes. Dettelbach, Germany: Psychometrica. Retrieved from https://www.psychometrica.de/ effect_size.html
Lozano, B. E., Birks, A. H., Kloezeman, K., Cha, N., Morland, L. A., & Tuerk, P. W. (2015). Therapeu- tic alliance in clinical videoconferencing: Optimiz- ing the communication context. In P. W. Tuerk & P. Shore (Eds.), Clinical videoconferencing in tele- health (pp. 221–251). Cham, Switzerland: Spring- er. http://dx.doi.org/10.1007/978-3-319-08765- 8_10
Luxton, D. D., Sirotin, A. P., & Mishkind, M. C. (2010). Safety of telemental healthcare delivered to clinically unsupervised settings: A systematic review. Telemedicine Journal and e-Health, 16, 705–711. http://dx.doi.org/10.1089/tmj.2009.0179
Meissner, T. (2017). Video conferencing for mind- fulness programs: Benefits, experiences, and rec- ommendations. International Journal of Whole Person Care, 4, 4–15. http://dx.doi.org/10.26443/ ijwpc.v4i2.126
Mindfulness All-Party Parliamentary Group (MAPPG). (2015). Mindful Nation U. K. Retrieved from https://www.themindfulnessinitiative.org/ mindful-nation-report
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). The PRISMA statement for reporting sys- tematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Medicine, 6, e1000100.
Naslund, J. A., Aschbrenner, K. A., Araya, R., Marsch, L. A., Unützer, J., Patel, V., & Bartels, S. J. (2017). Digital technology for treating and preventing mental disorders in low-income and middle-income countries: A narrative review of the literature. The Lancet Psychiatry, 4, 486–500. http://dx.doi.org/10.1016/S2215-0366(17)30096-2
NHS England. (2019). The NHS long term plan. Retrieved from https://bit.ly/2SMHePF
Norcross, J. C., Pfund, R. A., & Prochaska, J. O. (2013). Psychotherapy in 2022: A Delphi poll on its future. Professional Psychology, Research and Practice, 44, 363–370. http://dx.doi.org/10.1037/ a0034633
O’Connor, S., Hanlon, P., O’Donnell, C. A., Garcia, S., Glanville, J., & Mair, F. S. (2016). Understand- ing factors affecting patient and public engage- ment and recruitment to digital health interven- tions: A systematic review of qualitative studies. BMC Medical Informatics and Decision Making, 16, 120. http://dx.doi.org/10.1186/s12911-016- 0359-3
Office for National Statistics. (2018). Internet access. Households and individuals, Great Britain: 2018. Retrieved from https://bit.ly/2FbWZI8
Parsons, C. E., Crane, C., Parsons, L. J., Fjorback, L. O., & Kuyken, W. (2017). Home practice in Mindfulness-Based Cognitive Therapy and Mind- fulness-Based Stress Reduction: A systematic re- view and meta-analysis of participants’ mindful- ness practice and its association with outcomes. Behaviour Research and Therapy, 95, 29– 41. http://dx.doi.org/10.1016/j.brat.2017.05.004
Pinsof, W. M., & Catherall, D. R. (1986). The inte- grative psychotherapy alliance: Family, couple and individual therapy scales. Journal of Marital and Family Therapy, 12, 137–151. http://dx.doi.org/10 .1111/j.1752-0606.1986.tb01631.x
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., . . . Duffy, S. (2006). Guid- ance on the conduct of narrative synthesis in sys- tematic reviews. A product from the ESRC meth- ods programme Version, 1, b92.
Pote, H., Moulton-Perkins, A., Griffith, E., Latch- ford, G., Raczka, R., & Cavanagh, K., . . . Laidlaw, K. (2020). Digital competencies for psychological professions. Digital Health Skills. Retrieved from https://www.digitalhealthskills.com/
Russell, L., Ugalde, A., Milne, D., Austin, D., & Livingston, P. M. (2018). Digital characteristics and dissemination indicators to optimize delivery of internet-supported mindfulness-based interven- tions for people with a chronic condition: System- atic review. JMIR Mental Health, 5, e53. http://dx .doi.org/10.2196/mental.9645
Sansom, S., Crane, R., Karunavira Koerbel, L., & Yiangou, A. (2020). Addendum to the Mindful- ness-Based Interventions Teaching Assessment Criteria (MBI-TAC) for assessing online delivery of Mindfulness-Based Programmes. Retrieved from http://mbitac.bangor.ac.uk/mbitac-tool .php.en
Sansom-Daly, U. M., Wakefield, C. E., McGill, B. C., & Patterson, P. (2015). Ethical and clinical challenges delivering group-based cognitive-
19SYSTEMATIC REVIEW OF MBCT/MBSR BY VIDEOCONFERENCING
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
behavioural therapy to adolescents and young adults with cancer using videoconferencing tech- nology. Australian Psychologist, 50, 271–278. http://dx.doi.org/10.1111/ap.12112
Schoultz, M., Macaden, L., & Hubbard, G. (2016). Participants’ perspectives on mindfulness-based cognitive therapy for inflammatory bowel disease: A qualitative study nested within a pilot ran- domised controlled trial. Pilot and Feasibility Studies, 2, 3. http://dx.doi.org/10.1186/s40814- 015-0041-z
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.
Seres, M. (2015). Why can’t patients receive blood results via text or use Skype for appointments? The Guardian. Retrieved from https://bit.ly/2ZREWR3
Sevilla-Llewellyn-Jones, J., Santesteban-Echarri, O., Pryor, I., McGorry, P., & Alvarez-Jimenez, M. (2018). Web-based mindfulness interventions for mental health treatment: Systematic review and meta-analysis. JMIR Mental Health, 5, e10278. http://dx.doi.org/10.2196/10278
Simmons, G., & Redman, J. (2018). Teaching mind- fulness online. Journal of the Australian and New Zealand Student Services Association, 26, 3390. http://dx.doi.org/10.30688/janzssa.2018.07
Simpson, S. G., & Reid, C. L. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. The Australian Journal of Rural Health, 22, 280–299. http://dx.doi.org/10.1111/ajr.12149
Spijkerman, M. P., Pots, W. T. M., & Bohlmeijer, E. T. (2016). Effectiveness of online mindfulness- based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 45, 102–114. http://dx.doi.org/10.1016/j.cpr.2016.03.009
Strauss, C., Cavanagh, K., Oliver, A., & Pettman, D. (2014). Mindfulness-based interventions for peo- ple diagnosed with a current episode of an anxiety or depressive disorder: A meta-analysis of ran- domised controlled trials. PLoS ONE, 9, e96110. http://dx.doi.org/10.1371/journal.pone.0096110
Stronge, A. J., Rogers, W. A., & Fisk, A. D. (2007). Human factors considerations in implementing telemedicine systems to accommodate older adults. Journal of Telemedicine and Telecare, 13, 1–3. http://dx.doi.org/10.1258/1357633077779 7701158
Sustrans. (2012). Locked out: Transport poverty in England. Retrieved from https://bit.ly/2SHC6wg
Thomas, B. H., Ciliska, D., Dobbins, M., & Micucci, S. (2004). A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions. Worldviews on Evidence-Based Nursing, 1, 176–184. http://dx.doi .org/10.1111/j.1524-475X.2004.04006.x
Thomas, J., O’Mara-Eves, A., Kneale, D., & Shemilt, I. (2017). Synthesis methods for combining and configuring quantitative data. In D. Gough, S. Ol- iver, & J. Thomas (Eds.), An introduction to sys- tematic reviews (2nd ed., pp. 211–250). London, UK: Sage.
Toivonen, K. I., Zernicke, K., & Carlson, L. E. (2017). Web-based mindfulness interventions for people with physical health conditions: Systematic review. Journal of Medical Internet Research, 19, e303. http://dx.doi.org/10.2196/jmir.7487
Valentine, J. C., Wilson, S. J., Rindskopf, D., Lau, T. S., Tanner-Smith, E. E., Yeide, M., . . . Foster, L. (2017). Synthesizing evidence in public policy contexts: The challenge of synthesis when there are only a few studies. Evaluation Review, 41, 3–26. http://dx.doi.org/10.1177/0193841X166 74421
Visted, E., Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2015). The impact of group-based mindful- ness training on self-reported mindfulness: A sys- tematic review and meta-analysis. Mindfulness, 6, 501–522. http://dx.doi.org/10.1007/s12671-014- 0283-5
Zernicke, K. A., Campbell, T. S., Speca, M., Mc- Cabe-Ruff, K., Flowers, S., & Carlson, L. E. (2014). A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness- based cancer recovery program: The eTherapy for cancer applying mindfulness trial. Psychosomatic Medicine, 76, 257–267. http://dx.doi.org/10.1097/ PSY.0000000000000053
Zernicke, K. A., Campbell, T. S., Speca, M., McCabe Ruff, K., Flowers, S., Tamagawa, R., & Carlson, L. E. (2016). The eCALM trial: ETherapy for cancer applying mindfulness. Exploratory analyses of the associations between online mindfulness- based cancer recovery participation and changes in mood, stress symptoms, mindfulness, posttrau- matic growth, and spirituality. Mindfulness, 7, 1071–1081. http://dx.doi.org/10.1007/s12671-016- 0545-5
Received April 26, 2020 Revision received July 20, 2020
Accepted July 22, 2020 �
20 MOULTON-PERKINS ET AL.
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
- Systematic Review of Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction ...
- Aim and Review Questions
- Method
- Design
- Inclusion and Exclusion Criteria
- Search Strategy
- Procedure
- Analytic Strategy
- Results
- Study Characteristics
- Feasibility and Acceptability
- Safety
- Study Quality
- Efficacy
- Discussion
- Characteristics of Included Studies
- Feasibility and Acceptability
- Safety
- Efficacy
- Strengths and Limitations
- Further Research
- References
