Effects of mindfulness-based interventions on depressive symptoms in patients with substance use disorders: a systematic review and meta-analysis

No.	Searches	Results
1	Search mindfulness OR mindful* OR meditation OR meditat*	14,861
2	Search (“mindfulness”[Mesh])OR “meditation” [Mesh]	5353
3	Search ((mindfulness OR mindful* OR meditation OR meditat*)) OR ((“mindfulness”[Mesh])OR “meditation” [Mesh])	14,861
4	Search (substance use disorder) OR (substance use) OR (drug addict*)	91,476
5	Search (“substance-related disorders”[Mesh] or (“substance abuse treatment centers” [Mesh] OR “substance abuse, Intervenous” [Mesh] OR “psychoses, substance-induced” [Mesh] OR “substance abuse, oral” [Mesh] OR “substance withdrawal syndrome”[Mesh])	276,574
6	Search (“substance-related disorders”[Mesh] or (“substance abuse treatment centers” [Mesh] OR “substance abuse, Intervenous” [Mesh] OR “psychoses, substance-induced” [Mesh] OR “substance abuse, oral” [Mesh] OR “substance withdrawal syndrome”[Mesh]) OR ((substance use disorder) OR (substance use) OR (drug addict*))	313,986
7	Search ((mindfulness OR mindful* OR meditation OR meditat)) OR ((“mindfulness”[Mesh])OR “meditation” [Mesh]) AND ((((“substance-related disorders”[Mesh] or (“substance abuse treatment centers” [Mesh] OR “substance abuse, Intervenous” [Mesh] OR “psychoses, substance-induced” [Mesh] OR “substance abuse, oral” [Mesh] OR “substance withdrawal syndrome”[Mesh]) OR ((substance use disorder) OR (substance use) OR (drug* addict*))))	599
8	Search ((mindfulness OR mindful* OR meditation OR meditat)) OR ((“mindfulness”[Mesh])OR “meditation” [Mesh]) AND ((((“substance-related disorders”[Mesh] or (“substance abuse treatment centers” [Mesh] OR “substance abuse, Intervenous” [Mesh] OR “psychoses, substance-induced” [Mesh] OR “substance abuse, oral” [Mesh] OR “substance withdrawal syndrome”[Mesh]) OR ((substance use disorder) OR (substance use) OR (drug* addict*)))) Filters: Clinical trial	100
9	Search ((mindfulness OR mindful* OR meditation OR meditat)) OR ((“mindfulness”[Mesh])OR “meditation” [Mesh]) AND ((((“substance-related disorders”[Mesh] or (“substance abuse treatment centers” [Mesh] OR “substance abuse, Intervenous” [Mesh] OR “psychoses, substance-induced” [Mesh] OR “substance abuse, oral” [Mesh] OR “substance withdrawal syndrome”[Mesh]) OR ((substance use disorder) OR (substance use) OR (drug* addict*)))) Filters: Clinical trial; Review	215
10	Search ((mindfulness OR mindful* OR meditation OR meditat)) OR ((“mindfulness”[Mesh])OR “meditation” [Mesh]) AND ((((“substance-related disorders”[Mesh] or (“substance abuse treatment centers” [Mesh] OR “substance abuse, Intervenous” [Mesh] OR “psychoses, substance-induced” [Mesh] OR “substance abuse, oral” [Mesh] OR “substance withdrawal syndrome”[Mesh]) OR ((substance use disorder) OR (substance use) OR (drug* addict*)))) Filters: Clinical trial; Review; Publication date from 2018/01/01 to 2020/12/31	50

Table 2.

Quality indicators of included primary studies (n = 19).

Author(s)/years	Assignment into groups	Concealed allocation	Masked data collector	Intention-to-treat	A priori of power	Compared groups at baseline	Baseline characteristics equal	Fidelity check	Interventionist trained
Alexander (2018)³¹	5	0	0	0	0	1	0	0	1
Bevan (2012)³²	1	1	0	0	0	1	0	0	0
Cooperman et al. (2021)³³	1	1	0	0	0	1	0	1	1
de Souza et al. (2020)⁴⁴	1	0	0	0	0	1	1	1	1
Glasner-Edwards et al. (2017)³⁴	1	1	0	1	0	1	1	1	1
Hosseinzadeh and Barahmand (2014)⁴⁶	1	0	0	1	0	1	1	1	1
Machado et al. (2020)⁴⁵	2	0	0	1	0	1	1	1	1
Nakamura et al. (2015)³⁵	1	0	0	1	0	1	1	1	NR
Price et al. (2012)³⁷	1	0	0	1	0	1	1	1	1
Price et al. (2019)³⁶	1	1	1	1	1	1	1	0	1
Rogojanski et al. (2011)⁴⁷	1	0	0	1	1	1	1	1	NR
Ross et al. (2019)³⁸	1	0	0	1	0	0	NR	1	NR
Sarvandani et al. (2021)⁴¹	5	0	0	1	1	0	NR	0	NR
Shareh et al. (2018)⁴²	1	0	0	0	0	1	1	1	NR
Spears et al. (2017)³⁹	1	0	0	0	0	0	NR	0	NR
Wongtongkam et al. (2018)⁴⁹	1	0	0	0	0	1	0	0	1
Yadav (2016)⁴⁸	1	0	0	0	0	1	1	0	NR
Zemestani and Ottaviani (2016)⁴³	5	1	1	1	0	1	1	0	1
Zullig et al. (2021)⁴⁰	3	0	0	0	0	1	1	0	1

1 Note: Quality indicators: 0, No; 1, Yes; ND, no dropouts; NR, not reported, except; Assignment into groups: 1, individual randomization; 2, non-randomization.

Table 3.

Summary demographic of included primary studies (n = 19).

No.	Author	Study design	Samples/setting	Age mean ± SD	MMI/control Control	MMIs characteristics	F/U (month)	Measures	Results	Comments
1	Alexander (2018)³¹, USA	Quasi	83 SUD mothers with depression A comprehensive treatment facility	30.5 48% <30 years.	70/13	- MBSR - 2 h/week over 12 weeks. - workbook with guided stretching, yoga, relaxation exercise and meditations (iPod NANO)	-	BDI	At baseline: MMI: 18.51 (11.1) Control: 16.46 (9.03) At posttest: mean difference - MMI: -3.9 (10.1) - Control: 6.8 (13.2) t (71) =-2.44, P < 0.05	- 92% unemployed - 75% white - Attrition rate: 32% MMIs and 29% control
2	Bevan (2012)³², USA	RCT	75 inpatients with SUD 42 males 33 females Drug and alcohol treatment center	42 (11)	35/40	- A 5-d MBI training first. - Then 30 min./session over 14 weeks. -	2 weeks.	DASS-21	At 2 weeks. F/U Depression: MMI: 22.09 (11.69) to 8.40 (8.95) Waitlist: 28.1 (14.99) to 14.69 (12.34)	- 97% white - 37% married - 57% Employed - 40% unemployed - 73% alcoholism - 35% opiates - 45% used antidepressants - 32% used anti-anxiety medicine
3	Cooperman et al. (2021)³³, USA	RCT	30 people with opioid use disorder and chronic pain 2 clinics in New Jersey, USA	50.4 (8.8)	15/15	Weekly as group format over 8 weeks, with 15 min. daily for home practice	4	CES-D	At 4 months F/U Depression: Mean difference: MORE: 7.7 (2.6), P = 0.012 TAU: 14.9 (2.7), P < 0.001	- 53% whites - 83% unemployed - 53% had low back pain, 40% arthritis - 67% used Heroin in past 30 d
4	De Souza et al. (2021)⁴⁴, Brazil	RCT	Adults with smoking Outpatient public health tobacco treatment service in Brazil	50.0 (10.5)	14/18	MBRP - 120 min/session weekly over 8 weeks, included guided meditation, exercise, discussion and homework review	4	HAD	At 4 months F/U. Depression: MBRP = 6.86 (1.17) Control = 6.00 (1.03)	- Small sample size - 63% Attrition rate
5	Glasner-Edwards et al. (2017)³⁴, USA	RCT	Stimulant dependent adults UCLA	45.3 (8.9)	14/12	MBRP - 75 min./session/week. over 8 weeks, with CD guided meditation - practice log with CD guided as home assignment	1	BDI-II	At 1 months F/U Depression: MMI: 14.5 (9.6) to 4.7 (6.9) HE: 15.6 (12.9) to 9.0 (8.5)	- Small sample size - High attrition rate (41%) - 70% males - 44% African American - 44% unemployed - 63% never married - 55% cocaine - 44% methamphetamine - 43% were diagnosed with mood disorders. - 58% Attrition rate - Small sample size
6	Hosseinzadeh et al. (2014)⁴⁶, Turkey	RCT	35 males with drug-dependent (opium or heroin) who suffered from depression	29.5	18/17	MBCT - 120 min/session over 8 weeks.	-	BDI-II	At posttest Depression: MBCT: 26.75 (12.26) to 16.94 (7.64) Control: 24.52 (8.46) to 23.65 (8.05) F = 71.31, P = 0.000	- Small sample size
7	Machado et al. (2020)⁴⁵, Brazil	RCT	42 patients in SUD treatment from Outpatient clinics in city of Sao Paulo	44 (11.2)	10/6	MBRP - 120 min/session weekly over 8 weeks.	3 months	CES-D	At 3 months F/U Experiment: 23.0 (13.7) to 12.4 (6.6) Control: 28.0 (14.4) to 27.1 (14.6) sig.	- 50%-75% attrition rate
8	Nakamura et al. (2015)³⁵, USA	RCT	Women with SUD 89% not married/separated/divorced 100% whites At a facility in Salt Lake City, Utah	MBB: 30.4 (8.3) TAU: 34.7 (10.2) Range 18-55	14/17	MBB - 20 sessions over 10 weeks.	-	CES-D	At posttest Depression MBB: 30.85 [27.94, 33.75] to 22.88 [19.59, 26.18] TAU: 31.11 [27.46, 34.76] to 24.19 [20.46, 27.91]	- Included only women - No F/U
9	Price et al. (2012)³⁷, USA	RCT	Women with SUD Nonprofit SUD treatment facility in the NW United States	39 Range 19-58	31/15	MABT 8 weekly sessions, 90 min/session	9	BSI	At 9 months F/U Depression: MABT 2.4 (0.34) to 0.90 (0.54) TAU: 2.2 (0.43) to 1.8 (0.69)	- Small sample size - 100% women - Participants in intervention group were highly SES - 94% whites - 65% unemployed - 71% pt. w/AUD
10	Price et al. (2019)³⁶, USA	RCT	Women with SUD-Nonprofit SUD treatment facility in the NW United States	35 Range 20-61	41/54	MABT 8 weekly sessions, 90 min./session	12	BDI-II	At 12 months F/U Depression MABT= 16.80 (11.1) to 12.30 (10.60) Control = 15.30 (10.50) to 11.50 (9.80)	- 75% whites - 51% unemployed - 100% any reported traumatic event - 82% intimate partner violence - All females
11	Rogojanski et al. (2011)⁴⁷, Canada	RCT	Adults with smoking Canadian city	40.34 (12.42)	31/30	Mindfulness intervention - 2 sessions spaced 7 d apart Suppression intervention (to avoid themselves from experience by actively avoiding the thoughts and feeling that arise)	7d	DASS-21	At 7 d F/U. Depression: Mindfulness: 12.70 (11.11) to 8.26 (8.58) Suppression gr.: 10.61 (11.59) to 12.70 (10.63) F(1,44) = 8.09, P = 0.007, Sig.	- The intervention was just a brief mindfulness intervention for coping with smoking urges - 41% participants were low nicotine dependence - 72% whites
12	Ross et al. (2020)³⁸, USA	RCT	Adults with SUD Two clinical sites	38.44 (10.92)	103/95	MBRP - 120 min/session weekly over 8 weeks, included guided meditation, exercise, discussion and homework review	-	BDI-II	At posttest Depression MBRP = mean difference = -0.01 (0.45) Control = mean difference =- 0.27 (0.43)	- 78% males - 48% non-whites
13	Sarvandani et al. (2021)⁴¹, Iran	Quasi	Adults with SUD Addition treatment clinics in Kerman	NR	25/25	MBSR - 8 sessions over 8 weeks, included raisin meditation and body scan and sitting meditation and mindfulness movement	-	BDI-II	At posttest Depression MBI = 33.86 (9.82) to 28.68 (7.45) Control = 34.36 (9.86) to 33.84 (10.24)	- Small sample size
14	Shareh et al. (2018)⁴², Iran	RCT	40 adolescents with methamphetamine- addicted Addiction treatment center	28.41	20/20	MBRP - 9, 60 min./session. biweekly over 4 weeks.	-	BDI-II	At posttest Depression: MBRP: 29.4 (6.18) to 17.14 (5.59) Control: 31.27 (7.17) to 26.31 (6.64)	- No F/U
15	Spears, et al. (2017)³⁹, USA	RCT	Adults with smoking	> 18 years	154/103	MBAT - 120 min/session over 8 weeks, with group counseling	-	CESD	- MBAT vs. Usual care Depression -.18[-0.40, 0.03], P = 0.099	- 48% African American - 42% non-Latino - 55% females - Mean 20 cigarettes/d
16	Wongtongkam et al. (2018)⁴⁹, Thailand	RCT	Adults with alcohol dependence Rehabilitation center, Thailand	40.22 (8.74)	23/15	Vipassana mindfulness meditation 120 min/daily for consecutive day	-	BDI-21	At posttest: Depression: MMI: 16.04 (6.53) to 13.86 (9.18) Control: 17.27 (7.59) to 16.78 (8.54)	- 100% males - Small sample size - Long-term F/U is needed - 90% of participants drank alcohol every day, two bottles of alcohol on weekend recruited by staffs—maybe selection bias
17	Yadav (2016)⁴⁸, India	RCT	Patients with AUD All males Central Institute of Psychiatry, India	35.67 (7.75)	15/15	Body scan meditation 60 min/session	-	HAM-D	HDRS: MMI: 3.0 (1.51) to 2.0 (1.61) Control: 3.66 (1.79) to 2.93 (1.49)	- 100% males - 86% employed - 66.6% married - Small sample size - Severity of alcohol dependence (SADQ) of experimental gr. was 33.6 (5.64), while control gr. was 39.6 (5,68)
18	Zemestani and Ottaviani (2016)⁴³, Iran	RCT	74 adults with SUD At the treatment community center in Ahvaz, Iran	30.1 (9.7)	37/37	MBRP - 120 min/session/week. over 8 weeks.	2	BDI-II	At 2 months F/U Depression MBRP: 31.2 (5.1) to 18.3 (4.7) Control: 30.8 (4.3) to 28.1 (4.3) Sig. (F = 30.7, P < 0.0001)	- 80% males - 36% married - 30% divorced/separated - 64% unemployed - 40% methamphetamine - 18% cocaine - 44% were diagnosed with MDD - 37% comorbid anxiety disorders
19	Zullig et al. (2021)⁴⁰, USA	Qua-si	Patients receiving MOUD	36.3 (NR)	45/35	MBRP - 60 min./biweekly over 24 weeks.	4 months	ODSIS	Depression score was different compared control group. (F = 5.94, P < 0.0001)	- 27% attrition rate

1 Note¹. AUD, alcohol use disorder; BDI-II, Beck Depression Inventory; BSI, Brief Symptom Inventory; CES-D, Center for Epidemiological Studies Depression; DASS-21, Depression Anxiety and Stress Scales;

HAD, Hospital Anxiety and Depression Scale; HAM-D, Hamilton Depression Rating Scale; MABT, mindful awareness in body-oriented therapy; MBB, Mind Body Bridging; MBCT, mindfulness-based cognitive therapy; MBI, mindfulness-based intervention; MBRR mindfulness-based relapse prevention; MBSR, mindfulness-based stress reduction; MOUD, medication for opioid use disorder, NR, not reported; ODSIS, Overall Depression Severity and Impairment Scale; SUD, substance use disorder; HE, Health education; MM, Mindfulness Meditation; MMI, Mindfulness Meditation Intervention; NANO, An Apple iPod Nano; NW, Northwestern; RCT, Randomized Controlled Trial; SMD, Standard Mean Difference; SES, Socioeconomic status; HDRS, Hamilton Depression Rating scale.

Table 4.

Characteristics of primary studies.

Characteristic	n	Min	Q1	Mdn.	Q3	Max	Mean	SD
Mean age (years)	15	28.4	32.4	38.4	44.0	50.4	38.6	7.0
Total sample size at analysis
MBI group	19	10.0	15.0	23.0	37.0	154.0	36.1	36.4
Control group	19	6.0	15.0	18.0	37.0	103.0	30.4	26.9
Female	8	0	0	29.9	43.7	50.0	24.6	22.3
White	6	0	27.5	72.9	97.0	100.0	63.1	38.3
African American	4	0	0.3	16.1	47.7	53.3	21.4	25.6
Asian	4	0	0.3	1.2	75.3	100.0	25.6	49.6
Weeks of structured MBI	19	1.0	5.0	8.0	8.0	48.0	8.8	10.0
Days across intervention (length)	19	5.0	28.0	49.0	49.0	322.0	55.4	67.7
Structured MBI session/week	19	1.0	1.0	1.0	2.0	7.0	2.0	2.0
Structured MBI min./session	16	20.0	63.8	120.0	120.0	120.0	95.0	33.3
Dose (length × duration)	16	100.0	2178.8	5880.0	5880.0	19,320.0	5306.9	4514.8
Days after intervention measured
Attrition, MBI group	18	0	0	19.3	54.6	59.1	23.1	24.4
Attrition, control group	18	0	0	8.1	31.2	70.0	19.6	24.9

1 Note: Max, maximum; MBI, mindfulness-based intervention; Mdn, median; Min, minimum; Q1, first quartile; Q3, third quartile.

Table 5.

ES of MBI vs control groups.

Comparison	MM group
Comparison	k	ES	P (ES)	95% CI	SE	I²	Q	p (Q)
MBI vs. control groups	19	0.67	0.001	0.29, 1.05	0.19	89.59	172.87	<0.001
Single group MBI
Pre- vs. post- (r = 0.0)	14	0.90	<0.001	0.51, 1.29	0.20	75.44	52.94	<0.001
Pre- vs. post- (r = 0.8)	14	0.95	<0.001	0.59, 1.30	0.18	94.42	232.98	<0.001
Control group
Pre- vs. post- (r = 0.0)	14	0.29	0.036	0.02, 0.56	0.14	61.47	33.74	0.001
Pre- vs. post- (r = 0.8)	14	0.28	0.025	0.04, 0.52	0.12	90.81	141.41	<0.001

1 Note: CI, confidence interval; ES, effect size; MBI; mindfulness-based intervention; SE, standard error.

Effect of MBI on depressive symptoms in patients with SUD.
*Note:* ES, effect size; SUD, substance use disorder; CI, confidence interval; MBI, mindfulness-based intervention.

Table 6.

Categorical moderator results for depression comparing MBI versus control groups.

Moderator	k	ES	SE	Var.	95% CI	Z	p(Z)	^Qbet	P (Q_bet)
Source characteristics
Funding								0.033	0.856
Unfunded	8	0.725	0.294	0.087	0.148, 1.301	2.463	0.014
Funded	11	0.654	0.254	0.065	0.156, 1.153	2.573	0.010
Type of publication								0.036	0.982
Journal article	16	0.683	0.221	0.049	0.025, 1.116	3.096	0.002
Dissertation	2	0.787	0.608	0.369	-0.404, 1.977	1.295	0.195
Thesis	1	0.600	0.895	0.802	-1.155, 2.354	0.670	0.503
Method characteristics
Blinded data collection								0.349	0.554
No	17	0.634	0.210	0.044	0.222, 1.045	3.021	0.003
Yes	2	1.004	0.590	0.348	-0.153, 2.160	1.701	0.089
Intention-to-treat								1.066	0.302
No	8	0.437	0.311	0.097	-0.173, 1.046	1.403	0.161
Yes	11	0.863	0.271	0.073	0.332, 1.393	3.185	0.001
Concealed allocation								2.946	0.086
No	14	0.478	0.220	0.048	0.047, 0.909	2.174	0.030
Yes	5	1.221	0.373	0.139	0.490, 1.952	3.275	0.001
Baseline characteristics equal across groups								0.444	0.505
No	3	0.629	0.468	0.219	-0.288, 1.545	1.344	0.179
Yes	12	0.980	0.245	0.060	0.500, 1.460	4.000	<0.001
Fidelity								0.460	0.498
No	12	0.577	0.251	0.063	0.085, 1.069	2.296	0.022
Yes	7	0.865	0.342	0.117	0.195, 1.535	2.53	0.011
Intervention characteristics
MBI type								0.100	0.992
MBSR	1	0.567	0.911	0.831	-1.219, 2.353	0.622	0.534
MBCT	1	0.833	0.936	0.876	-1.001,2.668	0.891	0.373
Adapted MBI	9	0.732	0.308	0.095	0.128, 1.337	2.375	0.018
MBRP	8	0.624	0.329	0.108	-0.021, 1.269	1.896	0.058
Group discussion								0.027	0.869
No	6	0.688	0.343	0.117	0.017, 1.360	2.008	0.045
Yes	12	0.619	0.239	0.057	0.150, 1.089	2.587	0.010
Counseling								0.211	0.646
No	12	0.578	0.239	0.057	0.110, 1.046	2.421	0.015
Yes	6	0.768	0.338	0.114	0.106, 1.430	2.274	0.023
Home assignment								0.427	0.514
No	8	0.763	0.270	0.073	0.234, 1.293	2.826	0.005
Yes	10	0.525	0.246	0.061	0.042, 1.008	2.128	0.033
Structure MBI format								6.790	0.034
Individual	8	0.330	0.288	0.083	-0.235, 0.895	1.145	0.252
Group	8	0.639	0.293	0.086	0.066, 1.213	2.185	0.029
Mixed (individual + group)	2	2.130	0.628	0.394	0.899, 3.361	3.392	0.001
Outcome measure
Days after intervention measured								0.001	0.974
Immediate post-MBI	7	0.671	0.335	0.112	0.014, 1.328	2.001	0.045
Delayed follow-up	12	0.685	0.260	0.067	0.175, 1.194	2.635	0.008

1 Note: Adapted MBIs, adapted mindfulness-based interventions; CI, confidence interval; ES, k, number of comparisons; MBCT, mindfulness-based cognitive therapy; MBI, mindfulness-based intervention; MBRP, mindfulness-based relapse prevention; MBSR, mindfulness-based stress reduction; NR, not reported; Q, heterogeneity statistics; SE, standard error; Var., variance.

Table 7.

Continuous moderators of the effects of mindfulness-based intervention on depression.

Moderator	k	Slope	SE	Tau²	Q_model	P-value
Study characteristic
Publication year	19	-0.007	0.062	0.70	0.01	0.917
Sample characteristic
Age (mean)	15	-0.004	0.038	0.83	0.01	0.918
Women	7	0.014	0.022	1.36	0.41	0.520
Method characteristic
Attrition	18	-0.004	0.010	0.76	0.15	0.703
Reliability of depressive instruments	8	0.337	2.69	0.32	0.02	0.900
Intervention characteristics
Intervention length (total week)	19	0.001	0.021	0.70	0.00	0.962
Online MBI sessions/week	6	0.036	0.132	0.44	0.08	0.783
Duration of online MBI min./session	16	0.001	0.008	0.86	0.01	0.922
Dose (length × duration)	16	0.000	0.000	0.86	0.01	0.933
Days after intervention measured	19	-0.001	0.002	0.69	0.14	0.706

1 Note: k, number of comparisons; MBI, mindfulness-based intervention; Q, heterogeneity statistics; SE, standard error.

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DOI: https://doi.org/10.2478/fon-2023-0016 | Journal eISSN: 2544-8994 | Journal ISSN: 2097-5368

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Language: English

Page range: 145 - 162

Submitted on: Sep 27, 2022

Accepted on: Nov 28, 2022

Published on: Jun 22, 2023

Published by: Shanxi Medical Periodical Press

In partnership with: Paradigm Publishing Services

Keywords:

depression,

meditation,

mindfulness,

patients with substance use disorders,

systematic review and meta-analysis

Related subjects:

Medicine,

Assistive professions, nursing

© 2023 Chuntana Reangsing, Sasinun Pusuwun, Suneerat Boonsin, Sarah Oerther, published by Shanxi Medical Periodical Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 10 (2023): Issue 2 (June 2023)

Effects of mindfulness-based interventions on depressive symptoms in patients with substance use disorders: a systematic review and meta-analysis

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