PTSD symptom reduction with mindfulness-based stretching and deep breathing exercise: randomized controlled clinical trial of efficacy

The effect of slow breathing in regulating anxiety

Anxiety is an interactive disorder of the mind and body, characterized by excessive worry about uncertain future events and a dysfunction of the autonomic nervous system. Previous studies have shown that slow, deep breathing can reduce physical tension, and anxiety. Although we know that slow and deep breathing techniques can effectively regulate anxiety and other emotions, the psychological and neurophysiological mechanisms of slow breathing on anxiety have not been systematically explored. In the study, we combined the paced breathing task with the threat uncertainty task for the first time to investigate the role of slow breathing in regulating anxiety. Here we investigated this question, using Spectral analysis and Time-frequency domain of EEG to assess brain activity relating respiratory rate and the mechanism of respiratory rate impact on the anxious. Twenty-seven individuals participated in the experiment, which followed a 2 (respiratory rate: fast breathing, slow breathing) × 2 (certainty: certain, uncertain) within-subjects design. The results of showed that: (1) Slow breathing effectively reduced anxiety, the valence and arousal are lower under the slow breathing. (2) The EEG of fast and slow breathing showed different characteristics. There is an overall increase in power during slow breathing in the delta, theta, alpha and beta bands.(3) The interaction of respiratory rate and certainty were closely related to beta. In the uncertain, beta power decreased with slow breathing but increased with fast breathing.

Group integrated exercise versus recovery class for veterans with posttraumatic stress disorder: a randomized clinical trial

There are no reported randomized trials testing exercise versus an active comparator for Posttraumatic Stress Disorder (PTSD). This randomized clinical trial assessed the effectiveness of group exercise versus psychoeducation to improve quality of life and reduces symptomatic severity in Veterans with PTSD. Veterans who met criteria for current PTSD (DSM-5) and/or endorsed moderate levels of PTSD symptoms (CAPS 5 score ≥ 23) were randomly assigned to treatment. Integrative Exercise (IE) combines fitness exercises (aerobics, resistance training, stretching) with mindful body/breath awareness versus Recovery Class (REC) psychoeducation control condition. A total of 84 participants were enrolled of which 41 participants were randomized to IE and 43 participants to REC. There were no significant pre-post differences in change in the WHOQOL Psychological Domain in either group. There was a modest reduction in the total CAPS-5 score in both groups (IE: -8.2 (9.9), p < .001: REC: -7.8 (2.0), p < .001) but no differences across the two conditions. In the IE subsample that was remote, there was a greater improvement in PTSD symptom severity (F[1, 50] = 4.62, p = .036) and in in the WHOQOL Psychological Domain (F(1, 47) = 6.46, p = .014) in those who attended more sessions. Trial registration ClinicalTrials.gov Identifier: NCT02856412 (registration date: February 27, 2017).

Physiology mechanisms of exercise for PTSD: a narrative review

In at-risk societies, the population of post-traumatic stress disorder (PTSD) incidence is gradually expanding from veterans to the general public. In the face of the high incidence of PTSD, exercise therapy, as an economical and maneuverable treatment, has not received the attention it deserves. In this paper, the literature on PTSD symptom improvement through comb-climbing exercise interventions found that performing long-term exercise can achieve significant improvement in PTSD symptoms by modulating the central nervous system, autonomic nervous system, and immune system at the physiological level. Aerobic exercise (running, walking) is beneficial to the central nervous system and immune system; anaerobic exercise positively affects the autonomic nervous system, including resistance or strength endurance training; yoga, which focuses on flexibility and balance training, has a positive effect on the immune system. Future research should explore the neutral and negative effects and mechanisms of exercise on PTSD interventions. Expand more empirical studies in special occupational populations. And implement longitudinal intervention studies with PTSD patients to gain an in-depth understanding of PTSD intervention effects.

Effectiveness of Meditation Techniques in Treating Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis

Background and Objectives: Post-traumatic stress disorder (PTSD) is a debilitating condition worldwide. The limited effectiveness of current psychological and pharmacological treatments has motivated studies on meditation techniques. This study is a comprehensive, multiple-treatments meta-analysis comparing the effectiveness of different categories of meditation in treating PTSD. Methods and Materials: We followed Prisma guidelines in our published protocol to search major databases and to conduct a meta-analysis of the studies. Results: We located 61 studies with 3440 subjects and divided them logically into four treatment groups: Mindfulness-Based Stress Reduction (MBSR, 13 studies); Mindfulness-Based Other techniques (MBO, 16 studies), Transcendental Meditation (TM, 18 studies), and Other Meditations that were neither mindfulness nor TM (OM, 14 studies). Trauma populations included war veterans, war refugees, earthquake and tsunami victims, female survivors of interpersonal violence, clinical nurses, male and female prison inmates, and traumatized students. Of those offered, 86% were willing to try meditation. The baseline characteristics of subjects were similar across meditation categories: mean age = 52.2 years, range 29-75; sample size = 55.4, range 5-249; % males = 65.1%, range 0-100; and maximum study duration = 13.2 weeks, range 1-48. There were no significant differences between treatment categories on strength of research design nor evidence of publication bias. The pooled mean effect sizes in Hedges's g for the four categories were MBSR = -0.52, MBO = -0.66, OM = -0.63, and TM = -1.13. There were no appreciable differences in the study characteristics of research conducted on different meditations in terms of the types of study populations included, outcome measures, control conditions, gender, or length of time between the intervention and assessment of PTSD. TM's effect was significantly larger than for each of the other categories, which did not differ from each other. No study reported serious side effects. Conclusions: All categories of meditation studied were helpful in mitigating symptoms of PTSD. TM produced clinically significant reductions in PTSD in all trauma groups. We recommend a multisite Phase 3 clinical trial to test TM's efficacy compared with standard treatment.

Mindfulness-Based Interventions and the Hypothalamic-Pituitary-Adrenal Axis: A Systematic Review

BACKGROUND

Numerous studies have evaluated the effect that mindfulness-based interventions (MBIs) have on multiple health outcomes. For its part, stress is a natural response to environmental disturbances and within the associated metabolic responses, alterations in cortisol levels and their measurement in different tissues are a way to determine the stress state of an individual. Therefore, it has been proposed that MBIs can modify cortisol levels.

METHODS AND RESULTS

The objective of this systematic review was to analyze and summarize the different studies that have evaluated the effect of MBIs on cortisol levels. The following databases were consulted: MEDLINE, AMED, CINAHL, Web of Science, Science Direct, PsycINFO, SocINDEX, PubMed, the Cochrane Library and Scopus. The search terms "mindfulness", "mindfulness-based interventions" and "cortisol" were used (and the search was limited to studies from January 1990 to May 2024). In order to reduce selection bias, each article was scrutinized using the JBI Critical Appraisal Checklist independently by two authors. We included those studies with specified intervention groups with at least one control group and excluded duplicate studies or those in which the intervention or control group was not adequately specified. Significant changes in cortisol following MBIs were found in 25 studies, while 10 found no changes. The small sample size, lack of randomization, blinding, and probable confounding and interaction variables stand out in these studies.

CONCLUSION

MBIs have biological plausibility as a means of explaining a positive effect on cortisol levels; however, the weakness of the studies and the absence of robust designs makes it difficult to establish a causal association between both variables.

REGISTRATION NUMBER

INPLASY2024110017.

Advances in Exercise in the Clinical Trials of Migraine: A Scoping Review

PURPOSE OF REVIEW

This review aimed to investigate emerging evidence regarding the effectiveness of exercise for migraines, focusing on the results of recent trials. Additionally, it explored the possibility of exercise as a treatment for migraines.

RECENT FINDINGS

Between 2020 and 2023, five, four, one, and two trials were conducted regarding the effect of aerobic exercise, anaerobic exercise, Tai Chi, and yoga, respectively, on migraine; all studies showed significant effects. Two trials on aerobic exercise showed that high-intensity exercise was similar to or slightly more effective than moderate-intensity exercise as a treatment for migraines. Three trials on anaerobic exercise reported its effectiveness in preventing migraines. Regarding efficacy, side effects, and health benefits, aerobic exercises and yoga are potentially beneficial strategies for the prevention of migraines. Further studies are needed to develop evidence-based exercise programs for the treatment of migraines.

Effects of mindfulness-based cognitive therapy for Chinese adults with PTSD symptoms: protocol for a randomised controlled trial

INTRODUCTION

Emerging evidence supports mindfulness as a potential psychotherapy for post-traumatic stress disorder (PTSD). Individuals with subthreshold PTSD experience significant impairment in their daily life and functioning due to PTSD symptoms, despite not meeting the full diagnostic criteria for PTSD in DSM-5. Mindfulness skills, including non-judgmental acceptance, attentional control and openness to experiences may help alleviate PTSD symptoms by targeting characteristics such as intensified memory processing, dysregulated hyperarousal, avoidance, and thought suppression. This trial aims to test the effects of mindfulness-based cognitive therapy (MBCT) when compared to an active control.

METHOD AND ANALYSIS

This 1:1 randomised controlled trial will enroll 160 participants with PTSD symptoms in 2 arms (MBCT vs. Seeking Safety), with both interventions consisting of 8 weekly sessions lasting 2 h each week and led by certified instructors. Assessments will be conducted at baseline (T0), post-intervention (T1), and 3 months post-intervention (T2), with the primary outcome being PTSD symptoms measured by the PTSD checklist for DSM-5 (PCL-5) at T1. Secondary outcomes include depression, anxiety, attention, experimental avoidance, rumination, mindfulness, and coping skills. Both intention-to-treat and per-protocol analyses will be performed. Mediation analysis will investigate whether attention, experimental avoidance, and rumination mediate the effect of mindfulness on PTSD symptoms.

DISCUSSION

The proposed study will assess the effectiveness of MBCT in improving PTSD symptoms. The findings are anticipated to have implications for various areas of healthcare and contribute to the enhancement of existing intervention guidelines for PTSD.

TRIAL REGISTRATION NUMBER

ChiCTR2200061863.

The role of neurosteroids in posttraumatic stress disorder and alcohol use disorder: A review of 10 years of clinical literature and treatment implications

Rates of alcohol use disorder (AUD) are increasing in men and women and there are high rates of concurrent posttraumatic stress disorder (PTSD) and AUD. AUD and PTSD synergistically increase symptomatology and negatively affect treatment outcomes; however, there are very limited pharmacological treatments for PTSD/AUD. Neurosteroids have been implicated in the underlying neurobiological mechanisms of both PTSD and AUD and may be a target for treatment development. This review details the past ten years of research on pregnenolone, progesterone, allopregnanolone, pregnanolone, estradiol, testosterone and dehydroepiandrosterone/dehydroepiandrosterone-sulfate (DHEA/DHEA-S) in the context of PTSD and AUD, including examination of trauma/alcohol-related variables, such as stress-reactivity. Emerging evidence that exogenous pregnenolone, progesterone, and allopregnanolone may be promising, novel interventions is also discussed. Specific emphasis is placed on examining the application of sex as a biological variable in this body of literature, given that women are more susceptible to both PTSD diagnoses and stress-related alcohol consumption.

Effects of a diet low in excitotoxins on PTSD symptoms and related biomarkers

Post-traumatic stress disorder (PTSD) develops after trauma exposure and involves symptoms of avoidance, intrusive re-experiencing, mood and cognitive dysfunction, and hypervigilance. PTSD is often comorbid with Gulf War Illness (GWI), a neurological condition involving widespread pain, cognitive dysfunction, digestive problems, and other symptoms, in Gulf War veterans. PTSD tends to be more severe when comorbid with GWI. Low cortisol and elevated homocysteine levels have been found in PTSD, making them potential PTSD biomarkers. The low-glutamate diet, which aims to reduce excitotoxicity by eliminating the consumption of free glutamate and aspartate, has been shown to significantly reduce GWI and PTSD symptoms. This study examined whether changes in serum cortisol and homocysteine are associated with reduced PTSD severity in veterans with GWI after one month on the low-glutamate diet, and whether reducing the consumption of dietary excitotoxins was associated changes in PTSD and serum biomarkers. Data were analyzed for 33 veterans. No serum biomarkers significantly changed post-diet; however, cortisol increased as dietary excitotoxin consumption decreased, which held in a multivariable linear regression after adjustment for sex. Reduced dietary excitotoxin consumption was also associated with reduced hyperarousal symptoms, which held in a multivariable linear regression after adjustment for sex. Cortisol increase was associated with reduced avoidance symptoms after adjustment for change in BMI, and was marginally associated with overall PTSD reduction. Change in homocysteine was not significantly related to dietary adherence nor change in PTSD. Results suggest that reducing the consumption of dietary excitotoxins may normalize cortisol levels, which has been associated with alleviating PTSD.

Only Small Effects of Mindfulness-Based Interventions on Biomarker Levels of Inflammation and Stress: A Preregistered Systematic Review and Two Three-Level Meta-Analyses

Mindfulness-based interventions (MBIs) have a positive effect on biomarkers of inflammation and stress in patients with psychiatric disorders and physical illnesses. Regarding subclinical populations, results are less clear. The present meta-analysis addressed the effects of MBIs on biomarkers in psychiatric populations and among healthy, stressed, and at-risk populations. All available biomarker data were investigated with a comprehensive approach, using two three-level meta-analyses. Pre-post changes in biomarker levels within treatment groups (k = 40 studies, total N = 1441) and treatment effects compared to control group effects, using only RCT data (k = 32, total N = 2880), were of similar magnitude, Hedges g = -0.15 (95% CI = [-0.23, -0.06], p < 0.001) and g = -0.11 (95% CI = [-0.23, 0.001], p = 0.053). Effects increased in magnitude when including available follow-up data but did not differ between type of sample, MBI, biomarker, and control group or duration of the MBI. This suggests that MBIs may ameliorate biomarker levels in both psychiatric and subclinical populations to a small extent. However, low study quality and evidence of publication bias may have impacted on the results. More large and preregistered studies are still needed in this field of research.

Development and evaluation of an online mental health program for traumatized female college students: A randomized controlled trial

This study developed and evaluated an online mental health program for female college students who experienced trauma, based on Roy's Adaptation Model. A randomized controlled trial was adopted. Participants completed a survey on trauma and post-traumatic stress symptoms. Data from experimental and control groups (n = 16) were collected over two months. The program reduced post-traumatic stress and depression symptoms and improved functional health and adjustment. This effect was sustained in experimental group participants for one month post-program. The findings revealed the effectiveness of Internet mental healthcare for female students and the crucial role nurses play in it.

Work-Related Traumatic Stress Response in Nurses Employed in COVID-19 Settings

Nurses may be at a higher risk of experiencing work-related traumatic stress response during the COVID-19 pandemic compared to other clinicians. This study aimed to investigate the correlations between work-related trauma symptoms and demographic factors, psychosocial hazards and stress response in a census sample of nurses working in COVID-19 settings in Cyprus. In this nationwide descriptive and cross-sectional study, data were collected between April and May 2020 using a questionnaire that included sociodemographic, educational and employment and work-related variables, as well as a modified version of the Secondary Traumatic Stress Scale (STSS) for the assessment of work-related trauma symptoms during the pandemic. Overall, 233 nurses participated (with a response rate of 61.3%) and 25.7% of them reported clinical work-related trauma symptoms (STSS-M > 55; actual scale range: 17-85). The mean value for emotional exhaustion was 7.3 (SD: 2.29; visual scale range: 1-10), while the value for distress that was caused by being avoided due to work in COVID-19 units was 6.98 (SD: 2.69; visual scale range: 1-10). Positive associations were noted between trauma symptoms and both emotional exhaustion and distress from being avoided by others due to work in a COVID-19 setting and a negative association was also found between trauma symptoms and satisfaction from organizational support variables (all p < 0.002). Working in COVID-19 settings during the pandemic is a stressful experience that has been linked to psychologically traumatic symptoms Thus, supportive measures are proposed for healthcare personnel, even in countries with low COVID-19 burden.

Is exercise/physical activity effective at reducing symptoms of post-traumatic stress disorder in adults — A systematic review

Background

Exercise has been used to manage symptoms of post-traumatic stress disorder (PTSD). The effect of exercise on PTSD outcomes has been previously explored in several studies. However, it still remains unclear what type of exercise/physical activity, intensity and duration is most effective for reducing symptoms of PTSD. A systematic review was conducted to determine which forms of exercise or physical activity have the greatest effect on PTSD outcome scores including an evaluation of exercise frequency and volume.

Methods

The following electronic databases were systematically searched from January 1980 to June 2021: MEDLINE, PsycINFO, PubMed and Web of Science. Inclusion criteria were studies investigating adults aged 18 or over, reporting the effect of exercise and physical activities on PTSD symptom outcome scores. Two reviewers independently extracted information on study characteristics, exposure and outcomes. In total of 3,217 articles were screened and 23 full text articles further assessed, with 13 RCT's included in the review, covering seven exercise/physical activity interventions. The study protocol was registered prospectively with PROSPERO (CRD42021255131).

Results

Thirteen studies from four countries involving a total of 531 patients were selected for inclusion. Individual forms of exercise/physical activity examined showed some effect on reducing PTSD symptoms but combined exercises (resistance training, aerobic, strength and yoga) administered over a 12 week period, three times a week for 30–60 min showed greater effects on PTSD symptoms.

Conclusion

The limited evidence suggests that a combined exercise intervention has the best evidence for a having a beneficial effect on PTSD symptoms.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255131.

Workplace interventions to prevent or reduce post-traumatic stress disorder and symptoms among hospital nurses: A scoping review

OBJECTIVES

The aim of this study was to identify literature on evaluated workplace interventions to prevent or reduce the prevalence or impact of work-related post-traumatic stress disorder (PTSD) and PTSD symptoms among hospital nurses. A second objective was to summarise and compare the characteristics and effectiveness of these interventions.

BACKGROUND

A substantial proportion of nurses report PTSD symptoms. Previous reviews have synthesised interventions to address PTSD in military and other high-risk populations, but similar work focusing on nurses has yet to be conducted.

METHODS

We conducted a scoping review with the question: What interventions have been studied to prevent or treat PTSD symptoms or PTSD among nurses working in hospitals? We followed the PRISMA Scoping Review Checklist using an unregistered protocol. We searched in twelve academic and grey literature databases (e.g. MedLine, CINAHL) with no language restrictions. We included publications reporting on interventions which were evaluated for measurable impacts on PTSD and PTSD symptoms among nursing staff working in inpatient settings from 1980 to 2019, and charted study characteristics in a spreadsheet.

RESULTS

From 7746 results, 63 studies moved to full-text screening, and six studies met inclusion criteria. Methodologies included three randomised controlled studies, one quasi-experimental study, one pre-post feasibility study and one descriptive correlational study. Four studies reported a significant reduction in PTSD scores in intervention groups compared with baseline or comparison, when using debriefing, guided imagery or mindfulness-based exercises.

CONCLUSIONS

This review identified six studies evaluating hospital-based interventions to reduce PTSD and PTSD symptoms among hospital nurses, with some positive effects reported, contributing to a preliminary evidence base on reducing workplace trauma. Larger studies can compare nurse subpopulations, and system-level interventions should expand the focus from individuals to organisations.

RELEVANCE TO CLINICAL PRACTICE

This review can inform nursing and hospital leaders developing evidence-based interventions for PTSD among nurses.

Effectiveness of mindfulness-based intervention on post-traumatic stress symptoms among emergency nursing students

Background

Clinical training stress may negatively affect nursing students’ academic achievement, clinical performance, learning outcomes, well-being, general health, and quality of life. This study aimed to evaluate the effect of mindfulness-based intervention on post-traumatic stress symptoms among emergency nursing students. This study was conducted at the technical institute of nursing, Zagazig University. Three tools were used in the current study: the sociodemographic data sheet, the impact of event scale, and the 15-item Five-Facet Mindfulness Questionnaire.

Results

Emergency nursing students had a wide range of PTSS at the pre-intervention period. These symptoms significantly improved after the implementation of a mindfulness-based intervention. Mindfulness level also improved after the intervention. Post-traumatic stress symptoms were positively correlated with the number of training hours and negatively correlated with students’ age, mother’s occupation, and educational level.

Conclusions

Mindfulness-based intervention was effective in reducing post-traumatic stress symptoms among emergency nursing students.

Exploration of Trauma-Oriented Retreats: Quantitative Changes in Mental Health Measures for Canadian Military Members, Veterans and Royal Canadian Mounted Police with Posttraumatic Stress Disorder and Moral Injury

Background: Military members, veterans, and public safety personnel have been noted to have a higher risk of exposure to potentially traumatic events and potentially morally injurious events resulting in operational stress injuries (OSI) such as posttraumatic stress disorder (PTSD) and moral injury (MI). Treatments that can quickly and effectively address these conditions are desperately needed. The purpose of this research was to identify the impact of participation in a non-evidence-based trauma-oriented retreat for the above populations experiencing PTSD and MI. Methods: This study was an embedded mixed-methods longitudinal study with parallel repeated quantitative measures designed to evaluate outcomes at 1, 3, 6, and 12 months after completion of the retreat. Results: Analysis showed a statistically significant reduction in self-reported symptoms of PTSD, anxiety, stress, depression, MI, anger, and emotional dysregulation pre/post-retreat, and an increase in resilience. Self-reported longitudinal results did not see a change in symptom scores, with participants continuing to maintain their clinical diagnoses post-retreat. Conclusions: The results from this study illustrate that trauma-oriented retreats may be a complementary treatment modality for OSI-related conditions but should not be seen as a first-line treatment option. Program evaluation, determination of the evidence-based nature of retreats, and standardization are yet needed.

Mind–Body Exercises for PTSD Symptoms, Depression, and Anxiety in Patients With PTSD: A Systematic Review and Meta-Analysis

Objectives

This study aims to systematically analyze the effects of mind–body exercises on post-traumatic stress disorder (PTSD) symptoms, depression, and anxiety in patients with PTSD. Furthermore, it intends to provide scientific evidence-based exercise prescriptions.

Methods

Chinese (i.e., China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, and Wanfang) and English (i.e., Web of Science, PubMed, the Cochrane Library, and EMBASE) databases were used as data sources to search for studies on the effects of mind–body exercises on symptoms associated with patients with PTSD from January 1980 to November 2020. After a rigorous screening, 16 eligible randomized controlled trials (RCTs) were included in the meta-analysis.

Results

Mind–body exercises exerted a significant effect on PTSD symptoms [standard mean difference (SMD) = −0.41, 95% confidence interval (CI) −0.64 to −0.19, p < 0.001], depression (SMD = −0.35, 95% CI: −0.55 to −0.15, p < 0.001), and anxiety (SMD = −0.31, 95% CI: −0.74 to −0.12, p < 0.001) among patients with PTSD. Subgroup analysis demonstrated that 60–150 min per session for 8–16 weeks of mindfulness was more effective in improving symptoms in patients with PTSD under 45 years of age compared with other subgroups. For depression, 150–180 min of yoga exercises once per week was effective. For anxiety, the frequency, timing, duration, and type of mind–body exercises that are most effective in relieving anxiety in patients with PTSD cannot be determined at this time due to the limited number of eligible RCTs.

Conclusions

Mind–body exercises were found to be significantly effective in improving PTSD symptoms, depression, and anxiety in patients with PTSD. Therefore, they can be used as an adjunct to intervention for symptoms of patients with PTSD. However, this conclusion requires further confirmation through additional scientific and objective RCTs.

Systematic Review Registration:

Unique Identifier: INPLASY2020120072.

Gaming to cope: Applying network analysis to understand the relationship between posttraumatic stress symptoms and internet gaming disorder symptoms among disaster-exposed Chinese young adults

Research has demonstrated that posttraumatic stress disorder (PTSD) is associated with internet-related problematic behaviors. However, studies have not explored the linkage between PTSD symptoms and internet gaming disorder (IGD) symptoms. The current study aimed to investigate the relationship between posttraumatic stress symptoms (PTSS) and IGD symptoms via network analysis. We conducted a cross-sectional study with 341 Chinese young adults directly exposed to a typhoon and examined the network structure of PTSS and IGD symptoms, along with bridge symptoms, to elucidate how they co-occur. Results indicated that 'avoiding external reminders' and 'anhedonia' were identified as the most central symptoms in the PTSD network, whereas 'preoccupation,' 'gaming despite harms', and 'loss of control' ranked highest on centrality in the IGD network. Two bridge symptoms emerged within the combined PTSD and IGD network model: 'concentration difficulties' and 'conflict due to gaming' from among the PTSS and IGD symptoms, respectively. These findings reveal novel associations between PTSS and IGD symptoms and provide an empirically-based hypothesis for how these two disorders may co-occur among individuals exposed to natural disasters.

Addressing Acute Stress among Professionals Caring for COVID-19 Patients: Lessons Learned during the First Outbreak in Spain (March-April 2020)

Objectives: To describe lessons learned during the first COVID-19 outbreak in developing urgent interventions to strengthen healthcare workers' capacity to cope with acute stress caused by health care pressure, concern about becoming infected, despair of witnessing patients' suffering, and critical decision-making requirements of the SARS-CoV-2 pandemic during the first outbreak in Spain. Methods: A task force integrated by healthcare professionals and academics was activated following the first observations of acute stress reactions starting to compromise the professionals' capacity for caring COVID-19 patients. Literature review and qualitative approach (consensus techniques) were applied. The target population included health professionals in primary care, hospitals, emergencies, and nursing homes. Interventions designed for addressing acute stress were agreed and disseminated. Findings: There are similarities in stressors to previous outbreaks, and the solutions devised then may work now. A set of issues, interventions to cope with, and their levels of evidence were defined. Issues and interventions were classified as: adequate communication initiative to strengthen work morale (avoiding information blackouts, uniformity of criteria, access to updated information, mentoring new professionals); resilience and recovery from physical and mental fatigue (briefings, protecting the family, regulated recovery time during the day, psychological first aid, humanizing care); reinforce leadership of intermediate commands (informative leadership, transparency, realism, and positive messages, the current state of emergency has not allowed for an empirical analysis of the effectiveness of proposed interventions. Sharing information to gauge expectations, listening to what professionals need, feeling protected from threats, organizational flexibility, encouraging teamwork, and leadership that promotes psychological safety have led to more positive responses. Attention to the needs of individuals must be combined with caring for the teams responsible for patient care. Conclusions: Although the COVID-19 pandemic has a more devastating effect than other recent outbreaks, there are common stressors and lessons learned in all of them that we must draw on to increase our capacity to respond to future healthcare crises.

Sleep management in posttraumatic stress disorder: a systematic review and meta-analysis

OBJECTIVE

Post-traumatic stress disorder (PTSD) can lead to many negative secondary outcomes for patients, including sleep disturbances. The objective of this meta-analysis is (1) to evaluate the effect of interventions for adults with PTSD on sleep outcomes, PTSD outcomes, and adverse events, and (2) to evaluate the differential effectiveness of interventions aiming to improve sleep compared to those that do not.

METHODS

Nine databases were searched for relevant randomized controlled trials (RCTs) in PTSD from January 1980 to October 2019. Two independent reviewers screened 7176 records, assessed 2139 full-text articles, and included 89 studies in 155 publications for this review. Sleep, PTSD, and adverse event outcomes were abstracted and meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method for random effects.

RESULTS

Interventions improved sleep outcomes (standardized mean difference [SMD] -0.56; confidence interval [CI] -0.75 to -0.37; 49 RCTs) and PTSD symptoms (SMD -0.48; CI -0.67 to -0.29; 44 RCTs) across studies. Adverse events were not related to interventions overall (RR 1.17; CI 0.91 to 1.49; 15 RCTs). Interventions targeting sleep improved sleep outcomes more than interventions that did not target sleep (p = 0.03). Improvement in PTSD symptoms did not differ between intervention types.

CONCLUSIONS

Interventions for patients with PTSD significantly improve sleep outcomes, especially interventions that specifically target sleep. Treatments for adults with PTSD directed towards sleep improvement may benefit patients who suffer from both ailments.

Mindfulness as an intervention after multisystem trauma

Background

There is a known significant risk of negative mental health consequences following traumatic injury, yet no standard approach to prevent psychiatric illness in trauma patients currently exists. Mindfulness-based psychotherapies have been shown to reduce symptoms of post-traumatic stress disorder, depression and anxiety and improve resiliency, however it is unknown whether a mindfulness intervention immediately following traumatic injury would lead to diminished mental health consequences.

Methods

Multi-system trauma patients at the University of Alberta Hospital (N = 63) and the Foothills Hospital (N = 60) were assigned to the experimental and control groups respectively. Patients in the experimental group were asked to use the guided mindfulness application “Stop, Breathe & Think” for 28 consecutive days. All patients completed the Depression Anxiety Stress Scale (DASS-21) and Connor-Davidson Resilience Scale (CD-RISC) 48 hours and 28 days following admission. An exit interview was conducted for patients in the experimental group.

Results

There was no significant difference in mean enrollment DASS-21 scores, mean enrollment CD-RISC scores, mean follow-up DASS-21 scores and mean follow-up CD-RISC scores between experimental and control groups. Paired t-tests of mean admission and mean follow-up DASS-21 and CD-RISC scores were not significantly different in the experimental group. Paired t-tests of mean admission and follow-up CD-RISC scores were not significantly different in the control group whereas mean followup DASS-21 scores were decreased in the control group relative to enrolment DASS-21 scores (p = 0.014). Patients reported improved mood after use of mindfulness, and most planned to continue using the therapy and would recommend it to others.

Conclusion

Our study did not demonstrate an objective benefit of mindfulness intervention immediately following traumatic injury. Exit interview data suggests that a web-based mindfulness intervention may be beneficial for certain trauma patients however further research is required to identify those most likely to realize substantial gains.

Nature versus urban hiking for Veterans with post-traumatic stress disorder: a pilot randomised trial conducted in the Pacific Northwest USA

OBJECTIVES

To evaluate feasibility and acceptability of a group-based nature recreation intervention (nature hiking) and control condition (urban hiking) for military Veterans with post-traumatic stress disorder (PTSD).

DESIGN AND SETTING

A pilot randomised controlled trial conducted in the US Pacific Northwest.

PARTICIPANTS

Veterans with PTSD due to any cause.

INTERVENTIONS

Twenty-six participants were randomised to a 12-week intervention involving either six nature hikes (n=13) or six urban hikes (n=13).

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility was assessed based on recruitment, retention and attendance. Questionnaires and postintervention qualitative interviews were conducted to explore intervention acceptability. Questionnaires assessing acceptability and outcomes planned for the future trial (eg, PTSD symptoms) were collected at baseline, 6 weeks, 12 weeks (immediately after the final hike) and 24 weeks follow-up.

RESULTS

Of 415 people assessed for eligibility/interest, 97 were interested and passed preliminary eligibility screening, and 26 were randomised. Mean completion of all questionnaires was 91% among those in the nature hiking group and 68% in those in the urban hiking group. Over the course of the intervention, participants in the nature and urban groups attended an average of 56% and 58%, respectively, of scheduled hikes. Acceptability of both urban and nature hikes was high; over 70% reported a positive rating (ie, good/excellent) for the study communication, as well as hike locations, distance and pace. Median PTSD symptom scores (PTSD Checklist-5) improved more at 12 weeks and 24 weeks among those in the nature versus urban hiking group.

CONCLUSIONS

This pilot study largely confirmed the feasibility and acceptability of nature hiking as a potential treatment for Veterans with PTSD. Adaptations will be needed to improve recruitment and increase hike attendance for a future randomised controlled trial to effectively test and isolate the ways in which nature contact, physical activity and social support conferred by the group impact outcomes.

TRIAL REGISTRATION NUMBER

NCT03997344.

Non-pharmacological therapies for the treatment of post-traumatic stress disorder among emergency responders: a scoping review

OBJECTIVE

Identify non-pharmacological therapies for the treatment of post-traumatic stress disorder in emergency responders.

METHOD

Scope review according to the guidelines of the Joanna Briggs Institute and the PRISMA-ScR protocol. A search was conducted in nine databases, portals of theses and dissertations, and using an electronic search engine.

RESULTS

In total, 23 studies were selected and analyzed, and then categorized into six thematic fields - therapy with omega 3 food supplement, art therapy, physical exercise therapy, mindfulness-based therapy, therapy with elements of nature, and psychotherapy - which were considered non-pharmacological treatments for this psychopathology among emergency responders, as well as the use of psychotherapy via telehealth as an option for treatment.

CONCLUSION

More evidence supporting diet therapy is required, while the other therapeutic options presented positive results, finding support in national and international recommendations of treatment and clinical practice.

Effect of Mindfulness-Based Stress Reduction on dehydroepiandrosterone-sulfate in adults with self-reported stress. A randomized trial

Long‐term stress can lead to long‐term increased cortisol plasma levels, which increases the risk of numerous diseases. Dehydroepiandrosterone (DHEA) and its sulfated form dehydroepiandrosterone‐sulfate (DHEAS), together DHEA(S), have shown to counteract some of the effects of cortisol and may be protective during stress. The program “Mindfulness‐Based Stress Reduction” (MBSR) has shown to have positive effects on stress. The present study examined a possible effect of MBSR on DHEAS in plasma compared to a waiting list and a locally developed stress reduction program (LSR) in people with self‐reported stress. The study was a three‐armed randomized controlled trial conducted in a municipal health care center in Denmark. It included 71 participants with self‐reported stress randomized to either MBSR (n = 24) or LSR (n = 23), or a waiting list (n = 24). Blood samples were collected at baseline and at 12 weeks follow‐up to estimate effects of MBSR on DHEAS. The effect of MBSR on DHEAS was statistically significant compared to both the waiting list and LSR. We found a mean effect of 0.70 µmol/L (95% confidence interval [CI] = 0.18–1.22) higher DHEAS in the MBSR group compared with the waiting list group and a mean effect of 0.54 µmol/L (95% CI = 0.04–1.05) higher DHEAS in the MBSR group compared with the LSR group. Findings indicate an effect on DHEAS of the MBSR program compared to a waiting list and LSR program in people with self‐reported stress. However, we consider our findings hypothesis‐generating and validation by future studies is essential.

Mindfulness-based online intervention on mental health and quality of life among COVID-19 patients in China: an intervention design

BACKGROUND

COVID-19 can lead to increased psychological symptoms such as post-traumatic stress disorder (PTSD), depression, and anxiety among patients with COVID-19. Based on the previous mindfulness-based interventions proved to be effective, this protocol reports a design of a randomized controlled trial aiming to explore the efficacy and possible mechanism of a mindful living with challenge (MLWC) intervention developed for COVID-19 survivors in alleviating their psychological problems caused by both the disease and the pandemic.

METHODS

In April 2021, more than 1600 eligible participants from Hubei Province of China will be assigned 1:1 to an online MLWC intervention group or a waitlist control group. All participants will be asked to complete online questionnaires at baseline, post-program, and 3-month follow-up. The differences of mental health status (e.g. PTSD) and physical symptoms including fatigue and sleeplessness between the COVID-19 survivors who receiving the online MLWC intervention and the control group will be assessed. In addition, the possible mediators and moderators of the link between the MLWC intervention and target outcomes will be evaluated by related verified scales, such as the Five Facets Mindfulness Questionnaire. Data will be analyzed based on an intention-to-treat approach, and SPSS software will be used to perform statistical analysis.

DISCUSSION

The efficacy and potential mechanism of MLWC intervention in improving the quality of life and psychological status of COVID-19 survivors in China are expected to be reported. Findings from this study will shed light on a novel and feasible model in improving the psychological well-being of people during such public health emergencies. Trial registration Chinese Clinical Trial Registry (ChiCTR), ChiCTR2000037524; Registered on August 29, 2020, http://www.chictr.org.cn/showproj.aspx?proj=60034 .

The effect of reducing posttraumatic stress disorder symptoms on cardiovascular risk: Design and methodology of a randomized clinical trial

Posttraumatic stress disorder (PTSD) has been associated with accelerated progression of coronary heart disease (CHD). However, the underlying pathophysiological pathway has remained elusive and it is unclear whether there is a direct link between PTSD and CHD risk. This paper describes the methods of a randomized controlled trial developed to examine how changes in PTSD symptoms affect CHD disease pathways. One hundred twenty participants with current PTSD and who are free of known CHD will be randomized to receive either an evidence-based treatment for PTSD (Cognitive Processing Therapy; CPT) or a waitlist control (WL). Before and after CPT/WL, participants undergo assessment of CHD risk biomarkers reflecting autonomic nervous system dysregulation, systemic inflammation, and vascular endothelial dysfunction. The primary hypothesis is that individuals who show improvement in PTSD symptoms will show improvement in CHD risk biomarkers, whereas individuals who fail to improve or show worsening PTSD symptoms will have no change or worsening in CHD biomarkers. This study is expected to provide knowledge of the role of both the direct impact of PTSD symptoms on CHD risk pathways and the role of these systems as candidate mechanisms underlying the relationship between PTSD and CHD risk. Further, results will provide guidance on the utility of cognitive therapy as a tool to mitigate the accelerated progression of CHD in PTSD. Clinical Trials Registration: https://clinicaltrials.gov/ct2/show/NCT02736929; Unique identifier: NCT02736929.

Interventions and Manipulations of Interoception

Interoceptive pathways may be manipulated at various levels to develop interventions to improve symptoms in a range of disorders. Primarily through the lens of the respiratory system, we outline various pathways that can be manipulated at neural, behavioral, and psychological levels to change the representation of and attention to interoceptive signals, which can alter interconnected physiological systems and improve functioning and adaptive behavior. Interventions can alter interoception via neuromodulation of the vagus nerve, slow breathing to change respiratory rate and depth, or awareness processes such as mindfulness-based interventions. Aspects of this framework may be applied to other physiological systems and future research may integrate interventions across multiple levels of manipulation or bodily systems.

Psychological Interventions for Healthcare Providers With PTSD in Life-Threatening Pandemic: Systematic Review and Meta-Analysis

Objective: This study aims to evaluate the effect of psychological interventions on healthcare providers (HCP) with post-traumatic stress disorder (PTSD) due to their necessary exposure in life-threatening pandemic. Methods: We performed a systematic research on Medline, Embase, Cochrane Central, PsycInfo, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, ProQuest PTSD Pubs ProQuest Dissertations & Theses Global, and other gray databases by January 2021. Randomized controlled trials involving therapeutic interventions for HCP with PTSD were included. The primary outcome was PTSD symptom severity. Summary standardized mean differences (SMDs) and 95% confidence intervals were estimated using inverse variance meta-analysis with fixed effects. Risks of bias were assessed using Cochrane methods. Results: Among 773 citations, this review includes six studies, randomizing 810 participants. A meta-analysis of the effect of interventions compared to placebo showed a significant reduction of PTSD symptom severity: Cognitive Behavioral Therapy-Brief (CBT-B) (M = 27.80, 95% CI: 17.12, 38.48), Cognitive Behavioral Therapy-Long (CBT-L) (M = 26.50, 95% CI: 15.75, 37.25), and Mindfulness-Based Stretching and Deep Breathing Exercise (MBX) (M = 17.2, 95% CI: 6.57, 27.83). CBT-L and CBT-B also showed a significant effect on depression severity. Conclusions: The most effective and feasible treatment option for HCP with PTSD is still unclear, but CBT and MBX have displayed the most significant effects based on current limited evidence. Future research in this area-preferably large robust randomized controlled trials-is much needed.

Mindfulness and yoga for psychological trauma: systematic review and meta-analysis

Mindfulness-based interventions (MBIs), with postures, breath, relaxation, and meditation, such as Mindfulness-based Stress Reduction (MBSR) and yoga, are complex interventions increasingly used for trauma-related psychiatric conditions. Prior reviews have adopted a disorder-specific focus. However, trauma is a risk factor for most psychiatric conditions. We adopted a transdiagnostic approach to evaluate the efficacy of MBIs for the consequences of trauma, agnostic to diagnosis. AMED, CINAHL, Central, Embase, Pubmed/Medline, PsycINFO, and Scopus were searched to 30 September 2018 for controlled and uncontrolled trials of mindfulness, yoga, tai chi, and qi gong in people specifically selected for trauma exposure. Of >12,000 results, 66 studies were included in the systematic review and 24 controlled studies were meta-analyzed. There was a significant, pooled effect of MBIs (g = 0.51, 95%CI 0.31 to 0.71, p < .001). Similar effects were observed for mindfulness (g = 0.45, 0.26 to 0.64, p < .001), yoga (g = 0.46, 0.26 to 0.66, p < .001), and integrative exercise (g = 0.94, 0.37 to 1.51, p = .001), with no difference between interventions. Outcome measure or trauma type did not influence the effectiveness, but interventions of 8 weeks or more were more effective than shorter interventions (Q = 8.39, df = 2, p = .02). Mindfulness-based interventions, adjunctive to treatment-as-usual of medication and/or psychotherapy, are effective in reducing trauma-related symptoms. Yoga and mindfulness have comparable effectiveness. Many psychiatric studies do not report trauma exposure, focusing on disorder-specific outcomes, but this review suggests a transdiagnostic approach could be adopted in the treatment of trauma sequelae with MBIs. More rigorous reporting of trauma exposure and MBI treatment protocols is recommended to enhance future research.

Complementary and alternative therapies for post-traumatic stress disorder: A protocol for systematic review and network meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a psychiatric disorder. While bringing psychologic pain to patients, it also damages their social function, which is a great threat to people's life and health. Complementary and alternative medicine (CAM) therapies have been used clinically to treat PTSD; however, the selection strategies of different CAM interventions in clinical practice is still uncertain, and the purpose of this study is to evaluate the efficacy and acceptability of different CAM therapies using systematic review and network meta-analysis.

METHODS

According to the strategy, the authors will retrieve a total of 7 electronic databases by June 2020. After a series of screening, the 2 researchers will use Aggregate Data Drug Information System and Stata software to analyze the data extracted from randomized controlled trials of CAM therapies for the PTSD. Finally, the evidence grade of the results will be evaluated.

RESULTS

This study will provide a reliable evidence for the selection of CAM therapies for PTSD.

CONCLUSION

The results of this study will provide references for evaluating the influence of different CAM therapies for PTSD, and provide decision-making references for clinical research.

Meditation interventions efficiently reduce cortisol levels of at-risk samples: a meta-analysis

Previous meta-analytic results showed beneficial effects of meditation interventions for cortisol levels. In the present meta-analysis we tested whether effects are larger for those who might be in need of such stress reduction programs due to a risk for elevated cortisol levels as compared to no-risk samples. We included RCTs that measured change in cortisol levels. Based on 10 studies using blood samples meditation interventions had a significant, medium effect from pre-to post-test compared to the control group. Upon closer inspection, this effect was only present for at-risk samples, that is, patients with a somatic illness. In the 21 studies using saliva samples the effect was small and not significant, but there was a marginally significant effect for groups living in stressful life situations. This pattern may suggest that that meditation interventions are most beneficial for at-risk populations. These interventions might provide people with strategies of stress management that can contribute to well-being. Preliminary results suggest that benefits of meditation interventions might not fade with time.

Effect of a mindfulness intervention on patients admitted after multisystem trauma

Background

The incidence of depression, anxiety, and post-traumatic stress disorders is reported to be as high as 50% in trauma patients. The perpetual negative emotions and state of mind in these disorders predisposes patients to negative mental health outcomes. Mindfulness, on the other hand, helps people to process their experience and emotions in a non-judgmental manner, and recently, there has been increased utilization of mindfulness-based therapies for the treatment of mental health conditions. This proof-of-concept study evaluates the use of a mindfulness-based online application in patients admitted to the trauma service at a Level 1 Trauma Centre.

Methods

Trauma patients who were English speaking, over the age of 18, and without brain injury or pre-existing neurocognitive disorder were included. Participants completed the Depression Anxiety Stress Scale (DASS)-21 to assess level of depression, anxiety, and stress, and the Connor-Davidson Resilience Scale (CD-RISC) to assess level of resiliency. Then, after 28 consecutive days of practicing mindfulness using the app ‘Stop, Breathe, and Think,’ the questionnaires were repeated and an exit survey conducted.

Results

For this study, 13 participants were enrolled, 2 withdrew, and 5 were lost to follow-up. The mean DASS-21 score at time enrollment was 16.4 and was 11.2 at follow-up ( p = 0.10). There were no differences between the level of depression and stress from enrollment to follow-up, but there was significant decrease in anxiety symptoms from 7.2 to 3.0 (<0.05). CD-RISC scores at enrollment and follow-up were 77.8 and 81 ( p = 0.23), respectively. At the time of exit interview, 67% of patients continued to use the application three to four times a week and 67% responded they plan to continue using the application. In addition, 83% of patients always or often felt better after practicing mindfulness and stated they would recommend the application to others.

Conclusions

Mindfulness shows promising potential to decrease psychological distress in trauma patients.

Effects of Mindfulness-Based Interventions on Biomarkers and Low-Grade Inflammation in Patients with Psychiatric Disorders: A Meta-Analytic Review

Mindfulness-Based Interventions (MBIs) present positive effects on mental health in diverse populations. However, the detailed associations between MBIs and biomarkers in patients with psychiatric disorders remain poorly understood. The aim of this study was to examine the effects of MBIs on biomarkers in psychiatric illness used to summarise the effects of low-grade inflammation. A systematic review of PubMed, EMBASE, PsycINFO, and the Cochrane Library was conducted. Effect sizes (ESs) were determined by Hedges' g and the number needed to treat (NNT). Heterogeneity was evaluated. A total of 10 trials with 998 participants were included. MBIs showed significant improvements in the event-related potential amplitudes in attention-deficit hyperactivity disorder, the methylation of serotonin transporter genes in post-traumatic stress disorder, the salivary levels of interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-α) in depression, and the blood levels of adrenocorticotropic hormone (ACTH), IL-6, and TNF-α in generalised anxiety disorder. MBIs showed low but significant effects on health status related to biomarkers of low-grade inflammation (g = -0.21; 95% confidence interval (CI) -0.41 to -0.01; NNT = 8.47), with no heterogeneity (I² = 0; 95% CI 0 to 79). More trials are needed to establish the impact of MBIs on biomarkers in psychiatric illness.

Body- and Movement-Oriented Interventions for Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

To assess the efficacy of body- and movement-oriented interventions (BMOIs) in traumatized adults with posttraumatic stress disorder (PTSD), we conducted a systematic review and meta-analysis of pertinent literature. Four bibliographical databases (PsycINFO, Ovid MEDLINE(R), EMBASE, and the Cochrane Central Register of Controlled Trials) were searched using keywords and text words for trials on BMOIs addressing PTSD. The search included articles published between October 2005 and August 2017. Studies were included if participants were adults suffering from PTSD, if BMOIs were the therapeutic strategy under investigation, and if a psychometrically evaluated standardized outcome measure for PTSD was used. No limitations for control conditions were applied. Hedges' g was computed as the effect size (ES) for the treatment versus control condition. The meta-analysis included 15 studies, which resulted in a mean ES of g = 0.85, 95% CI [0.31, 1.39], with very high heterogeneity, I² = 91%. After removing one study as outlier, a mean effect size of g = 0.56, 95% CI [0.29, 0.82] (i.e., medium effect), still with considerable heterogeneity, I² = 57%, was found. BMOIs seem to be effective in reducing symptoms of PTSD, but more research is needed to identify working mechanisms and to determine which types of intervention are most effective for various subgroups of patients.

Brief mindfulness-based stress management program for a better mental state in working populations - Happy Nurse Project: A randomized controlled trial✰✰

BACKGROUND

The efficacy of the mindfulness-based stress management program for maintaining a better mental state has not been examined among working populations. We aimed to explore the effectiveness of the brief mindfulness-based stress management program for hospital nurses.

METHODS

In a multi-center randomized trial, 80 junior nurses working in hospitals were randomly allocated either to the brief mindfulness-based stress management program or psychoeducation using a leaflet. The program consisted of four 30 min individual sessions conducted by trained senior nurses using a detailed manual. The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) at week 26. Secondary outcomes included presence of a major depressive episode; severity of depression, anxiety, insomnia, burnout, and presenteeism; utility scores; and adverse events up to 52 weeks.

RESULTS

The mean HADS score of all the participants at baseline was 7.2. At 26 weeks, adjusted mean scores on the HADS score were 7.2 (95% confidence intervals: 5.9, 8. 5) in the program group and 6.0 (4.8, 7.2) in the leaflet group, respectively. The coefficient of the group by time interaction was not statistically significant at -1.41 (-3.35, 0.54; P = 0.156). No significant superiority or inferiority was observed on the other outcomes.

LIMITATIONS

We did not manage to recruit the number of participants we initially set out, although our post-hoc analyses showed that this did not lead to changes in our conclusions.

CONCLUSIONS

The additive value of the brief mindfulness-based stress management program was not confirmed in mental state and self-evaluated work efficiency.

Mindfulness training for healthcare professionals and trainees: A meta-analysis of randomized controlled trials

OBJECTIVE

Healthcare professionals (HCPs) experience a wide range of physical and psychological symptoms that can affect quality of patient care. Previous meta-analyses exploring mindfulness-based interventions (MBIs) for HCPs have been limited by their narrow scope regarding intervention type, target population, and/or measures, and reliance on uncontrolled studies; therefore, a more comprehensive and methodologically rigorous examination is warranted. This meta-analysis quantified the effectiveness of MBIs on distress, well-being, physical health, and performance in HCPs and HCPs-in-training.

METHOD

RCTs examining the effect of meditation and MBIs on HCPs and HCPs-in-training were identified and reviewed. Two independent reviewers extracted data and assessed risk of bias.

RESULTS

Thirty-eight studies were included in the analyses (n = 2505; 75.88% female). Intervention had a significant moderate effect on anxiety (Hedge's g = 0.47), depression (Hedge's g = 0.41), psychological distress (Hedge's g = 0.46), and stress (Hedge's g = 0.52). Small to moderate effects were also found for burnout (Hedge's g = 0.26) and well-being at post-intervention (Hedge's g = 0.32). Effects were not significant for physical health and performance. Larger intervention effects on overall outcomes were found with HCPs (Hedge's g = 0.52), with Mindfulness-based Stress Reduction intervention (Hedge's g = 0.47), and inactive controls (Hedge's g = 0.36).

CONCLUSIONS

Results suggest mindfulness-based interventions are effective in reducing distress and improving well-being in HCPs and HCP-ITs. Subgroup analyses suggest the importance of exploring potential participants' needs prior to selecting the type of mindfulness intervention. Future studies should assess changes in mindfulness and include active controls.

PHIT for Duty, a Mobile Application for Stress Reduction, Sleep Improvement, and Alcohol Moderation

Post-traumatic stress and other problems often occur after combat, deployment, and other military operations. Because techniques such as mindfulness meditation show efficacy in improving mental health, our team developed a mobile application (app) for individuals in the armed forces with subclinical psychological problems as secondary prevention of more significant disease. Based on the Personal Health Intervention Toolkit (PHIT), a mobile app framework for personalized health intervention studies, PHIT for Duty integrates mindfulness-based relaxation, behavioral education in sleep quality and alcohol use, and psychometric and psychophysiological data capture. We evaluated PHIT for Duty in usability and health assessment studies to establish app quality for use in health research. Participants (N = 31) rated usability on a 1 (very hard) to 5 (very easy) scale and also completed the System Usability Scale (SUS) questionnaire (N = 9). Results were (mean ± SD) overall (4.5 ± 0.6), self-report instruments (4.5 ± 0.7), pulse sensor (3.7 ± 1.2), sleep monitor (4.4 ± 0.7), sleep monitor comfort (3.7 ± 1.1), and wrist actigraphy comfort (2.7 ± 0.9). The average SUS score was 85 ± 12, indicating a rank of 95%. A comparison of PHIT-based assessments to traditional paper forms demonstrated a high overall correlation (r = 0.87). These evaluations of usability, health assessment accuracy, physiological sensing, system acceptability, and overall functionality have shown positive results and affirmation for using the PHIT framework and PHIT for Duty application in mobile health research.

The effects of a relaxation intervention on nurses' psychological and physiological stress indicators: A pilot study

The present pilot study was designed to examine the feasibility and the effects of a psychomotor relaxation program on nurses' psychological (burnout symptoms, affective states) and physiological stress indicators (salivary cortisol). Fifteen nurses engaged in an 8-week psychomotor relaxation program (two 20-min sessions per week) and 15 maintained their usual activities. The current study showed that the psychomotor relaxation program was feasible and well tolerated by the participants. Compared to the control group, the relaxation group showed a decrease in their levels of emotional exhaustion, depression and salivary cortisol. In the fifteenth session, salivary cortisol concentrations significantly decreased from pre-session to post-session. These results provide preliminary evidence that relaxation interventions are effective strategies for reducing the usual stress experienced by nurses, and demonstrate that a psychomotor relaxation program might be an important occupational stress-management tool for healthcare professionals.

Efficacy of equine-assisted psychotherapy in veterans with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a common and debilitating disorder among war veterans. Although complementary and alternative therapies are gaining acceptance in the treatment of PTSD, the efficacy of animal-based therapies in this disorder is unknown. The goal of equine-assisted psychotherapy (EAP) is to improve the social, emotional, and/or cognitive functions of individuals with PTSD.

OBJECTIVE

This study aims to explore the effects of EAP on PTSD symptoms. We hypothesized that veterans with PTSD who participate in a standardized EAP program for 1 h per week for 6 weeks would experience decreased PTSD symptoms and would demonstrate increased resilience as compared with individuals who do not receive EAP intervention.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

We conducted a sequentially assigned, two-arm parallel group trial comparing 6 weeks of EAP with standard, previously established, ongoing PTSD therapy. Therapy was conducted at a community EAP facility in conjunction with an academic University Hospital. Twenty adult veterans with symptomatic PTSD completed the study. Ten adult veterans with previously diagnosed PTSD were assigned to EAP and received directed interaction with trained horses for one hour a week in groups of 3 or 4 individuals, while also continuing their previously established therapies. A certified therapist supervised the sessions, and a professional horse handler was also present. Results were compared with those from 10 adult veterans who only received their standard previously established PTSD care as prescribed by their provider.

MAIN OUTCOME MEASURES

Changes in salivary cortisol, scores for the PTSD Check List-Military Version (PCL-M) and the Connor-Davidson Resilience Scale (CD-RISC) after 6 weeks of study were measured.

RESULTS

Of the 20 enrolled patients, 10 served in Afghanistan, 5 served in Iraq, and 3 served in Vietnam. Subjects were (47 ± 14) years old, were predominantly male, and had a body mass index of (29 ± 7) kg/m². They had (9.2 ± 6.1) years of military service and carried 66% ± 37% service-connected disability. PCL-M scores declined significantly in both groups and CD-RISC scores increased significantly in the EAP group. There was no difference between the groups with respect to the magnitude of change.

CONCLUSION

As compared to the control group, a 6-week EAP program did not produce a statistically significant difference with respect to PCL-M and CD-RISC scores, or salivary cortisol. However, our results suggest that EAP may work as well as standard therapy with respect to these parameters. This study supports further inquiry into EAP as a potentially efficacious alternative for veterans suffering from PTSD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT #03039361.

The impact of an exercise training intervention on cortisol levels and post-traumatic stress disorder in juveniles from an Ugandan refugee settlement: study protocol for a randomized control trial

Background

Latest research demonstrates a significant improvement in stress-related symptoms in psychological disorders as a result of exercise training (ET). Controlled clinical trials further validate the significance of ET by demonstrating lower salivary cortisol levels in patients with post-traumatic stress disorder (PTSD) after intervention. A significant change in cortisol and dehydroepiandrosterone (DHEA) levels can already be found after an 8–12-week ET program. The proposed study aims to investigate the impact of an 8-week ET on PTSD symptoms and changes in cortisol levels in a juvenile refugee sample from the Democratic Republic of the Congo (DRC) at an Ugandan refugee settlement. It is the first to implement an ET intervention in a resource-poor, post-conflict setting.

Methods/design

In a randomized controlled trial, 198 adolescent participants aged 13–16 years from the DRC who, suffer from PTSD, will be investigated. The participants are based at the Nakivale refugee settlement, an official refugee camp in Uganda, Africa, which is among the largest in the world. The participants will be randomized into an Exercise Training (ET) group with a maximum heart rate (HR_max) of > 60%, an Alternative Intervention (AI) group with low-level exercises, and a Waiting-list Control (WC) group. After the 8-week interventional phase, changes in cortisol awakening response (CAR) and DHEA in the ET group that correspond to an improvement in PTSD symptoms are expected that remain at follow-up after 3 months.

Discussion

To date, there is no controlled and reliable longitudinal study examining the effects of an ET program on symptom severity in individuals with PTSD that can be explained with a harmonization of cortisol secretion. The presented study design introduces an intervention that can be implemented with little expenditure. It aims to provide a promising low-threshold and cost-effective treatment approach for the application in resource-poor settings.

Trial registration

German Trials Register, ID: DRKS00014280. Registered prospectively on 15 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2753-x) contains supplementary material, which is available to authorized users.

Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials

Posttraumatic stress disorder (PTSD) is a chronic and debilitating disorder that affects the lives of 7-8% of adults in the U.S. Although several interventions demonstrate clinical effectiveness for treating PTSD, many patients continue to have residual symptoms and ask for a variety of treatment options. Complementary health approaches, such as meditation and yoga, hold promise for treating symptoms of PTSD. This meta-analysis evaluates the effect size (ES) of yoga and meditation on PTSD outcomes in adult patients. We also examined whether the intervention type, PTSD outcome measure, study population, sample size, or control condition moderated the effects of complementary approaches on PTSD outcomes. The studies included were 19 randomized control trials with data on 1173 participants. A random effects model yielded a statistically significant ES in the small to medium range (ES=-0.39, p<0.001, 95% CI [-0.57, -0.22]). There were no appreciable differences between intervention types, study population, outcome measures, or control condition. There was, however, a marginally significant higher ES for sample size≤30 (ES=-0.78, k=5). These findings suggest that meditation and yoga are promising complementary approaches in the treatment of PTSD among adults and warrant further study.

A systematic review of randomized trials of mind-body interventions for PTSD

OBJECTIVE

To systematically review outcomes from randomized controlled trials (RCTs) of mind-body treatments for PTSD.

METHODS

Inclusion criteria based on guidelines for assessing risk of bias were used to evaluate articles identified through electronic literature searches.

RESULTS

Twenty-two RCTs met inclusion standards. In most of the nine mindfulness and six yoga studies, significant between-group effects were found indicating moderate to large effect size advantages for these treatments. In all seven relaxation RCT's, relaxation was used as a control condition and five studies reported significant between-group differences on relevant PTSD outcomes in favor of the target treatments. However, there were large within-group symptom improvements in the relaxation condition for the majority of studies.

CONCLUSIONS

Although many studies are limited by methodologic weaknesses, recent studies have increased rigor and, in aggregate, the results for mindfulness, yoga, and relaxation are promising. Recommendations for design of future mind-body trials are offered.

Yoga for posttraumatic stress disorder - a systematic review and meta-analysis

BACKGROUND

Yoga is increasingly used as a therapeutic treatment and seems to improve psychiatric conditions such as anxiety disorders and depression. The aim of this systematic review was to assess the evidence of yoga for reducing symptoms of posttraumatic stress disorder (PTSD).

METHODS

The Cochrane Library, Medline/PubMed, PsycINFO, Scopus, and IndMED were searched through July 2017 for randomized controlled trials (RCTs) assessing the effects of yoga on symptoms of PTSD. Mean differences (MD) and standardized mean differences (SMD) with 95% confidence intervals (CI) were computed. The quality of evidence and the strength of recommendation were graded according to the GRADE recommendations.

RESULTS

Seven RCTs (N = 284) were included. Meta-analysis revealed low quality evidence for clinically relevant effects of yoga on PTSD symptoms compared to no treatment (SMD = - 1.10, 95% CI [- 1.72, - 0.47], p < .001, I² = 72%; MD = - 13.11, 95% CI [- 17.95, - 8.27]); and very low evidence for comparable effects of yoga and attention control interventions (SMD = - 0.31, 95%CI = [- 0.84, 0.22], p = .25; I² = 43%). Very low evidence was found for comparable retention of patients in the trial for yoga and no treatment (OR = 0.68, 95%CI [0.06, 7.72]) or attention control interventions (OR = 0.66, 95%CI [0.10, 4.46]). No serious adverse events were reported.

LIMITATIONS

Few RCTs with only limited sample size were available.

CONCLUSIONS

Only a weak recommendation for yoga as an adjunctive intervention for PTSD can be made. More high quality research is needed to confirm or disconfirm these findings.

Veterans Group Exercise: A randomized pilot trial of an Integrative Exercise program for veterans with posttraumatic stress

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent among military veterans and is associated with significant negative health outcomes. However, stigma and other barriers to care prevent many veterans from pursuing traditional mental health treatment. We developed a group-based Integrative Exercise (IE) program combining aerobic and resistance exercise, which is familiar to veterans, with mindfulness-based practices suited to veterans with PTSD. This study aimed to evaluate the effects of IE on PTSD symptom severity and quality of life, as well as assess the feasibility and acceptability of IE.

METHODS

Veterans (N = 47) were randomized to either IE or waitlist control (WL). Veterans in IE were asked to attend three 1-h group exercise sessions for 12 weeks.

RESULTS

Compared with WL, veterans randomized to IE demonstrated a greater reduction in PTSD symptom severity (d = -.90), a greater improvement in psychological quality of life (d = .53) and a smaller relative improvement in physical quality of life (d = .30) Veterans' ratings of IE indicated high feasibility and acceptability.

LIMITATIONS

The sample was relatively small and recruited from one site. The comparison condition was an inactive control.

CONCLUSIONS

This initial study suggests that IE is an innovative approach to treating veterans with symptoms of PTSD that reduces symptoms of posttraumatic stress and improves psychological quality of life. This approach to recovery may expand the reach of PTSD treatment into non-traditional settings and to veterans who may prefer a familiar activity, such as exercise, over medication or psychotherapy.

Does evidence support the high expectations placed in precision medicine? A bibliographic review

Background: Precision medicine is the Holy Grail of interventions that are tailored to a patient's individual characteristics. However, conventional clinical trials are designed to find differences in averages, and interpreting these differences depends on untestable assumptions. Although only an ideal, a constant effect of treatment would facilitate individual management. A direct consequence of a constant effect is that the variance of the outcome measure would be the same in the treated and control arms. We reviewed the literature to explore the similarity of these variances as a foundation for examining whether and how often precision medicine is definitively required. Methods: We reviewed parallel clinical trials with numerical primary endpoints published in 2004, 2007, 2010 and 2013. We collected the baseline and final standard deviations of the main outcome measure. We assessed homoscedasticity by comparing the variance of the primary endpoint between arms through the outcome variance ratio (treated to control group). Results: The review provided 208 articles with enough information to conduct the analysis. One out of five studies (n = 40, 19.2%) had statistically different variances between groups, implying a non-constant-effect. The adjusted point estimate of the mean outcome variance ratio (treated to control group) is 0.89 (95% CI 0.81 to 0.97). Conclusions: The mean variance ratio is significantly lower than 1 and the lower variance was found more often in the intervention group than in the control group, suggesting it is more usual for treated patients to be stable. This observed reduction in variance might also imply that there could be a subgroup of less ill patients who derive no benefit from treatment. This would require further study as to whether the treatment effect outweighs the side effects as well as the economic costs. We have shown that there are ways to analyze the apparently unobservable constant effect.

Does evidence support the high expectations placed in precision medicine? A bibliographic review

Background: Precision medicine is the Holy Grail of interventions that are tailored to a patient's individual characteristics. However, conventional clinical trials are designed to find differences in averages, and interpreting these differences depends on untestable assumptions. Although only an ideal, a constant effect of treatment would facilitate individual management. A direct consequence of a constant effect is that the variance of the outcome measure would be the same in the treated and control arms. We reviewed the literature to explore the similarity of these variances as a foundation for examining whether and how often precision medicine is definitively required. Methods: We reviewed parallel clinical trials with numerical primary endpoints published in 2004, 2007, 2010 and 2013. We collected the baseline and final standard deviations of the main outcome measure. We assessed homoscedasticity by comparing the variance of the primary endpoint between arms through the outcome variance ratio (treated to control group). Results: The review provided 208 articles with enough information to conduct the analysis. One out of five studies (n = 40, 19.2%) had statistically different variances between groups, implying a non-constant-effect. The adjusted point estimate of the mean outcome variance ratio (treated to control group) is 0.89 (95% CI 0.81 to 0.97). Conclusions: The mean variance ratio is significantly lower than 1 and the lower variance was found more often in the intervention group than in the control group, suggesting it is more usual for treated patients to be stable. This observed reduction in variance might also imply that there could be a subgroup of less ill patients who derive no benefit from treatment. This would require further study as to whether the treatment effect outweighs the side effects as well as the economic costs. We have shown that there are ways to analyze the apparently unobservable constant effect.