Mindfulness in people with a respiratory diagnosis: A systematic review
Introduction
The emotional impact of respiratory symptoms is profound. The experience of breathlessness promotes hyper-vigilance of respiratory symptoms [1] leading to increased stress, distress, anxiety and depression [2], [3], [4]. Anxiety about a distressing event can lead to post-traumatic stress disorder (PTSD) which has been found to affect 8% of individuals with stable chronic obstructive pulmonary disease (COPD) [5]. As the disease progresses acute exacerbations, characterized by a significant increase in breathlessness, become increasingly common. It is therefore likely that the prevalence of PTSD will increase as the disease progresses and as acute exacerbations increase in frequency and severity. Survivors of acute respiratory failure, severe enough to require mechanical ventilation, have symptoms of PTSD which may persist for one year post-hospitalization [2]. Stress, negative emotions and fear result in an unwillingness to participate in activities. Such avoidance promotes social isolation and further compromises exercise capacity and quality of life affecting the ability of patients with COPD to successfully manage their condition [6], [7].
Feelings of distress provide the focus of several theory-based interventions including; cognitive behavioral therapy (CBT) and mindfulness. Mindfulness aims to promote greater awareness of the unity between body and mind. Training involves developing a non-reactive awareness of thoughts, feelings and experiences which can undermine emotional and physical wellbeing [8]. Mindfulness can be delivered either on its own or as a key component of other therapies.
CBT emphasizes the identification and modification of maladaptive beliefs [9]. This may be difficult in the face of intense breathlessness as increased arousal and fear of death represent very real anxieties. Strategies to change thoughts may undermine legitimate feelings of anxiety associated with breathlessness, questioning the appropriateness of CBT alone [9]. Instead of altering cognitions it may be more helpful for individuals with respiratory conditions to modify their involvement with their thoughts, proposing a role for mindfulness.
A systematic review found mindfulness to be effective at improving mental health and depressive relapse compared to a wait list control or usual care group in a ‘healthy’ population. In clinical populations with physical illness, including multiple sclerosis, cancer and rheumatoid arthritis, it was found to be effective at improving health-related quality of life (HRQOL) and wellbeing, although these results were only applicable to participants who had the interest and ability to participate in mindfulness. Other limitations of studies included in the review involved a shortage of active control groups and a lack of long term follow up [10]. Since the conduction of this review other studies, conducted in chronic disease populations, have shown mindfulness to be effective in improving mood and reducing symptoms of distress in individuals with breast cancer, inflammatory joint disease and coronary heart disease [11], [12], [13].
The technique of mindfulness, which uses breathing as a focus of concentration to re-direct thoughts and prevent rumination, may have uniquely supportive features for those with respiratory symptoms. Alternatively, drawing attention to breathing in those with dyspnea could provoke hyper-vigilance of breathless symptoms resulting in emotional distress [1]. To date, the effect of mindfulness for patients with a respiratory diagnosis has not been systematically explored.
Therefore the specific study objectives were: (1) to describe how mindfulness is delivered and structured for adults with a respiratory diagnosis and (2) to examine the effect of mindfulness on psychosocial outcomes, namely HRQOL, mindful awareness and stress. Such findings may help clinicians apply mindfulness for individuals suffering from breathlessness.
Section snippets
Methods
This systematic review was registered with PROSPERO: CRD42015016954. The findings generated have been synthesized in a document consistent with PRISMA guidelines for reporting of systematic reviews and meta-analyses (Table 1) [14], [15].
Results
A total of 252 articles were reviewed, of which 239 were excluded after screening the title and abstract. Full text was obtained for 13 papers plus one additional reference which was identified following reference checks of the full texts. Ten studies were excluded following appraisal with reasons for exclusion documented in Fig. 1 [21], [22], [23], [24], [25], [26], [27], [28], [29], [30]. Four papers were included; two involved individuals with COPD [31], [32], one included an asthma
Discussion
This is the first review exploring the effect of mindfulness delivered to individuals with a respiratory diagnosis. Mindfulness interventions were based on the principles of MBSR but varied widely in terms of their delivery and the outcomes assessed. As per the results from the meta-analyses, no impact of Mindfulness was observed on disease-specific HRQOL, levels of mindful awareness or stress [31], [32], [33]. Positive between-group differences were not detected in generic HRQOL or anxiety [31]
Conflicts of interest
‘None’.
Role of funding
Financial support was provided by The Ontario Lung Association. DB holds a Canadian Research Chair. This work was funded by the Ontario Respiratory Care Society.
Contributors
Dr. Harrison: contributed to conceiving and designing the study, searching literature and extracting the data, interpreting the data, writing the manuscript, and approving the final version of the manuscript. Dr. Lee: contributed to searching literature and extracting the data, interpreting the data, writing the manuscript, and approving the final version of the manuscript. Dr. Janaudis-Ferreira: interpreting the data, writing the manuscript, and approving the final version of the manuscript.
Acknowledgements
John Tagg: contributed by designing and conducting the initial searches in collaboration with Dr. Harrison.
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