Effects of mindfulness-based intervention programs on sleep among people with common mental disorders: A systematic review and meta-analysis

Table 1 Characteristics of studies

Ref.	Country	Sample	Age range (mean)	Women, n (%)	Randomisation	Intervention group (comparison group)	Intervention duration	Group size for effect size calculation, n	Drop-out rate1 (%)	Outcome measure for sleep
Wahbeh[29], 2018	United States	Older adult with depression symptoms	55-80 (64.8)	21 (81)	R	IMMI (waitlist control)	6 wk	I = 26 C = 24	20.00	Sleep disturbance, ISI
Boettcher et al[50], 2014	Germany	Community dwellers with anxiety disorders	18+ (37)	34 (75.6)	R	IMMI (discussion forum control group)	8 wk	I = 45 C = 46	7.69	ISI
Wahbeh et al[47], 2016	United States	Combat veterans with post-traumatic stress disorder	25-65 (I = 53.3; C = 53.0)	2 (7)	R	MM (sitting quietly)	6 wk	I = 27 C = 25	0	PSQI
Britton et al[49], 2012	United States	Antidepressant medication users with sleep complaints	24-61 (47.0)	21 (80.8)	R	MBCT (control)	8 wk	I = 14 C = 10	7.69	TIB, TST, SE, SOL, WASO, TWT, Stage 1, SWS, Quality
Vøllestad et al[51], 2011	Norway	Community dwellers with anxiety disorders	18-65 (42.5)	26 (66.7)	R	MBSR (waitlist control)	8 wk	I = 39 C = 37	14	BIS
Britton et al[48], 2010	United States	Community dwellers with partially remitted depression	33-64 (45.4)	9 (69.2)	R	MBCT (control)	8 wk	I = 13 C = 8	19.23	TIB, TST, SE, SOL, WASO, NWAK, Arousals, Stage 1, SWS, Quality
Hoge et al[52], 2013	United States	Referral/community dwellers with generalized anxiety disorder	18+ (I = 41; C = 37)	23 (47.9)	R	MBSR (stress management education)	8 wk	I = 48 C = 45	4.30	Sleep quality, PSQI
Horenstein et al[45], 2019	United States	Adults with social anxiety disorder	18+ (32.7)	Not specified	R	MBSR (control)	12 wk	I = 36 C = 36	15.28	Sleep quality, PSQI
Pinniger et al[46], 2013	Australia	Adults with self-reported feelings of stress, anxiety, and/or depression	18-68 (39.5)	10 (90.9)	R	MM (waitlist control)	8 wk	I = 11 C = 23	30.60	Sleeping difficulty/insomnia, ISI
Stötter et al[31], 2013	Austria	Patients of the psychiatric hospital of Hall in Tirol	18+ (I = 42.8; C = 41.4)	11 (68.75)	R	MBTT (control)	8 wk	I = 14 C = 14	0	Sleep-onset disorder, Sleep maintenance disorders, Terminal sleep disorders, HDRS

¹When there are multiple intervention groups, the drop-out rate is based on the number of participants in Mindfulness-Based Program and comparison group only.

BIS: Bergen insomnia scale; C: Comparison group; I: Intervention; HDRS: Hamilton's depression rating scale; IMMI: Internet mindfulness meditation intervention; MBCT: Mindfulness-based cognitive therapy; MBSR: Mindfulness-based stress reduction; MBTT: Mindfulness-based touch therapy; NWAK: Number of awakenings; ISI: Insomnia severity index therapy; MM: Mindfulness meditation; PSQI: Pittsburgh sleep quality index; R: Randomised; SE: Sleep efficiency; SOL: Sleep onset latency; Stage 1: Sleep onset was defined by the first epoch of any stage of sleep; SWS: Short-wave sleep; TIB: Time in bed; TST: Total sleep time; TWT: Total wake time; WASO: Wake after sleep onset.

Table 2 Interventions' technique, components and selected outcome measures for effect size calculation

Mindfulness-based program	Intervention components		Selected outcome measures for effect size calculation	Ref.
	Intervention group	Comparison group
IMMI	DI + MM + MPS	WL	ISI	Wahbeh[29], 2018
	ME + psychoeducation	DF	ISI	Boettcher et al[50], 2014
MM	BS	SB	PSQI	Wahbeh et al[47], 2016
	BS	BS + SB	PSQI	Wahbeh et al[47], 2016
	BS	SQ	PSQI	Wahbeh et al[47], 2016
	BS + MB + MW + music meditation	WL	ISI	Pinniger et al[46], 2013
MBCT	MA + HW (Guided audio CD)	Control	Sleep diary	Britton et al[48], 2010
	MA (MB + MS + MW + lying + other simple movement) + HW (MM using audio CD + worksheet)	Control	Sleep diary	Britton et al[49], 2012
MBSR	BS + SM + MB + AR + DI + ME + MMV + HW	WL	Bergen insomnia scale	Vøllestad et al[51], 2011
	BS+ BA+ gentle Hatha Yoga	SME	PSQI	Hoge et al[52], 2013
	BS + SM + MS + MPS	WL	PSQI	Horenstein et al[45], 2019
MBTT	BA + touch + HW + counselling	BMT	HDRS	Stötter et al[31], 2013

AR: Adaptive response; BA: Bodily awareness; BMT: Basic medicinal therapy; BS: Body scan; DF: Discussion forum; DI: Didactic instruction; HDRS: Hamilton depression rating scale; HW: Homework; IMMI: Internet mindfulness meditation intervention; ISI: Insomnia severity index; MA: Mindfulness awareness; MB: Mindful breathing; ME: Mindfulness exercise; MBCT: Mindfulness based cognitive therapy; MBSR: Mindfulness based stress reduction; MBTT: Mindfulness based touch therapy; MM: Mindfulness meditation; MMV: Mindful movement; MPS: Mindfulness problem-solving; MS: Mindful stretching; MW: Mindful walking; PSQI: Pittsburgh sleep quality index; SB: Slow breathing; SM: Sitting meditation; SME: Stress management education; SQ: Sitting quietly; WL: Waitlist control.

Table 3 Research design and level of evidence

Ref.	Research design	Level of evidence
Wahbeh[29], 2018	RCT, crossover design	II
Boettcher et al[50], 2014	RCT, crossover design	II
Wahbeh et al[47], 2016	RCT, multi-group pre-/post-test design	II
Britton et al[49], 2012	RCT, pre-/post-test control group design	II
Vøllestad et al[51], 2011	RCT, crossover design	II
Britton et al[48], 2010	RCT, pre-/post-test control group design	II
Hoge et al[52], 2013	RCT, two group pre-/post-test design	II
Horenstein et al[45], 2019	RCT, multi-group pre-/post-test design	II
Pinniger et al[46], 2013	RCT, multi-group pre-/post-test design	II
Stötter et al[31], 2013	RCT, pre-/post-test control group design	II

RCT: Randomised controlled trial.

Table 4 Risk of bias in the studies

Ref.	Randomisation process	Deviation from intended intervention	Missing outcome data	Measurement of outcome	Selection of the reported results	Overall
Wahbeh[29], 2018	Low risk	Low risk	Some concerns	Some concerns	Low risk	High
Boettcher et al[50], 2014	Low risk	Low risk	Low risk	Some concerns	Low risk	Some concerns
Wahbeh et al[47], 2016	Low risk	Low risk	Low risk	Some concerns	Low risk	Some concerns
Britton et al[49], 2012	Low risk	Low risk	Low risk	Some concerns	Low risk	Some concerns
Vøllestad et al[51], 2011	Low risk	Low risk	Low risk	Some concerns	Low risk	Some concerns
Britton et al[48], 2010	Low risk	Some concerns	Low risk	Low risk	Low risk	Some concerns
Hoge et al[52], 2013	Low risk	Low risk	Low risk	Low risk	Low risk	Low
Horenstein et al[45], 2019	Low risk	Low risk	Low risk	Some concerns	Low risk	Some concerns
Pinniger et al[46], 2013	Low risk	High risk	Some concerns	Low risk	Low risk	High
Stötter et al[31], 2013	Low risk	Low risk	Low risk	Low risk	Low risk	Low

Table 5 Overall effects of different interventions

Ref.	Mindfulness-based program	k	Subjects, n	SMD (95%CI)	P value	Overall SMD (95%CI)	Overall P value	Q
Wahbeh[29], 2018	IMMI	2	124	-0.881 (-1.531 to -0.231)	0.008	-0.618 (-0.980 to -0.257)	0.001	0.912 (P = 0.34)
Boettcher et al[50], 2014				-0.500 (-0.935 to -0.066)	0.024
Wahbeh et al[47], 2016	MM	2	86	-0.267 (-0.814 to 0.279)	0.337	-0.264 (-0.699 to 0.172)	0.236	0.001 (P = 0.981)
Pinniger et al[46], 2013				-0.257 (-0.978 to 0.464)	0.485
Britton et al[48], 2010	MBCT	2	43	-1.073 (-1.953 to -0.192)	0.017	-1.003 (-1.645 to -0.360)	0.002	0.052 (P = 0.82)
Britton et al[49], 2012				-0.923 (-1.862 to 0.016)	0.054
Hoge et al[52], 2013	MBSR	3	187	-0.449 (-0.942 to 0.043)	0.074	-0.551 (-0.842 to -0.260)	< 0.0001	0.332 (P = 0.847)
Horenstein et al[45], 2019				-0.555 (-1.056 to -0.053)	0.03
Vøllestad et al[51], 2011				-0.660 (-1.178 to -0.141)	0.013
Stötter et al[31], 2013	MBTT	1	28	-1.138 (-1.937 to -0.340)	0.005	-1.138 (-1.937 to -0.340)	0.005	0 (P = 1)

CI: Confidence interval; IMMI: Internet mindfulness meditation intervention; MBCT: Mindfulness-based cognitive therapy; MBSR: Mindfulness-based stress reduction; MBTT: Mindfulness-based touch therapy; MM: Mindfulness meditation; SMD: Standardised mean difference.