International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Mindfulness in severe and persistent mental

illness: a systematic review

Angela Potes, Gabriel Souza, Katerina Nikolitch, Romeo Penheiro, Yara

Moussa, Eric Jarvis, Karl Looper & Soham Rej

To cite this article: Angela Potes, Gabriel Souza, Katerina Nikolitch, Romeo Penheiro, Yara
Moussa, Eric Jarvis, Karl Looper & Soham Rej (2018): Mindfulness in severe and persistent
mental illness: a systematic review, International Journal of Psychiatry in Clinical Practice, DOI:
10.1080/13651501.2018.1433857

To link to this article: https://doi.org/10.1080/13651501.2018.1433857

Published online: 07 Feb 2018.

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INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE, 2018
https://doi.org/10.1080/13651501.2018.1433857

REVIEW ARTICLE

Mindfulness in severe and persistent mental illness: a systematic review

Angela Potesa,b,c , Gabriel Souzaa,b,c, Katerina Nikolitchc, Romeo Penheirod, Yara Moussae, Eric Jarvisc,
Karl Loopera,b,c and Soham Reja,b,c
a
McGill Meditation and Mind-Body Medicine Research Clinic (MMMM-RC), Jewish General Hospital, Montr
eal, Canada; bGeri-PARTy Research
Group, Jewish General Hospital, Montr
eal, Canada; cDepartment of Psychiatry, McGill University, Montr
eal, Canada; dSunnybrook Health Sciences
Centre, Toronto, Ontario, Canada; eDepartment of Experimental Medicine, McGill University, Montr
eal, Canada

ABSTRACT ARTICLE HISTORY

Objective: This systematic review summarises the current state of research on mindfulness in SPMI, given Received 3 October 2017
the pressing need to provide alternative, scalable and cost-effective treatment modalities for patients with Revised 23 December 2017
severe and persistent mental illness (SPMI). Accepted 22 January 2018
Methods: Articles included mindfulness-based interventions for SPMI. Excluded articles included qualita-
KEYWORDS
tive studies, acceptance and compassion therapies, case reports and reviews. Studies were identified by Mindfulness; severe mental
searching the databases Medline, Embase and PsycINFO. illness; psychosis; bipolar
Results: Six randomised controlled trials, seven prospective studies and one retrospective study were
identified. Clinical improvements were observed on psychotic symptoms, and on improvements of depres-
sion symptoms, cognition, mindfulness, psycho-social and vocational factors.
Conclusions: Findings suggest that mindfulness is feasible for individuals with SPMI, and displays poten-
tial benefits in outcomes aside from psychotic symptoms. The effects of mindfulness in psychotic symp-
toms needs further investigation in larger definitive studies using methodological rigor and thorough
assessments of other psychiatric populations who are also representative of SPMI.

Introduction such as self-esteem and self-efficacy (Bach, Gaudiano, Pankey,

Nowadays, there is an increasing awareness of granting priority of
service to patients suffering from severe and persistent mental ill-
ness (SPMI) (Ruggeri, Leese, Thornicroft, Bisoffi, & Tansella, 2000).
Failing to engage patients with SPMI in mental health treatment
results in augmented health care system pressures and costs, espe-
cially as the number of mental health resources to address SPMI is
limited (Administration SAaMHS, 1999). Severe and persistent men-
tal illness (SPMI) has not been clearly defined (Ruggeri et al., 2000).
Yet, an overall consensus includes individuals with a diagnosis of a
mental disorder identified in need of long-term treatment (2 year
or longer history of mental illness or treatment), exhibiting severely
impaired behavioural and emotional functioning, interfering with
their capacity to remain in the community without supportive care
and results in dysfunctional capacities for daily living, interpersonal
relationships, employment and self-care (Administration SAaMHS,
1999; Anthony, 1993). SPMI patients require more support to
address their needs and are at risk of symptomatic decompensa-
tion, hospitalisation, poor social and clinical functioning and
decreased quality of life (Bellack, Bennett, Gearon, Brown, & Yang,
2006; Berren, Santiago, Zent, & Carbone, 1999).
Former approaches to treat SPMI include individual therapies
(e.g., motivational interviewing and cognitive behavioural therapy),
group therapies (e.g., stage-wise treatment group, social skills
training and self-help), family therapy, as well as pharmacological
treatment and vocational rehabilitation (Mueser, 2004). These
therapies have shown the importance of addressing psycho-social
functioning, but also promoting interventions aimed at
reducing perceived stress and improving subjective outcomes
Herbert, & Hayes, 2006). Newer ‘third wave’ interventions include
mindfulness-based therapies, which are increasing in popularity
(Allen, Chambers, & Knight, 2006), as they are reported to be scal-
able and cost-effective as they can be given as a group treatment
(Piet & Hougaard, 2011). Mindfulness is defined as ‘paying atten-
tion in a particular way: on purpose, in the present moment, and
non-judgmentally’ (Kabat-Zinn 1982). Mindfulness interventions
have been found effective for the treatment of psychological mor-
bidities and emotional distress in physical and mental illness
(Bishop et al., 2006), including recurrent major depressive disorder
(Piet & Hougaard 2011; Segal et al., 2010; Teasdale et al., 2000),
bipolar disorder (Chiesa & Serretti, 2011), chronic pain, stress, anx-
iety disorders (Grossman, Niemann, Schmidt, & Walach, 2004),
chronic physical illness (Fjorback, Arendt, Ornbol, Fink, & Walach,
2011), eating disorders (Wanden-Berghe, Sanz-Valero, & Wanden-
Berghe, 2010), cancer (Carlson et al., 2013) and substance use dis-
orders (Zgierska et al., 2009). As mindfulness-oriented practices
have been shown to enhance adaptive coping strategies and
reduce stress by promoting awareness of self, others, and the
environment (Chiesa & Serretti, 2011) as well as serving to the
regulation of negative emotions by embracing experience of the
present-moment (Khoury, Lecomte, Gaudiano, & Paquin, 2013),
recent studies have examined the impact of formal mindfulness
approaches, such as mindfulness-based stress reduction (MBSR)
and mindfulness-based cognitive therapy (MBCT) in SPMI
(Grossman et al., 2004).
The benefit of mindfulness-oriented practices in SPMI is still
emerging. Previous concerns of potential worsening of psychiatric

CONTACT Angela Potes angela.potesholguin@mail.mcgill.ca Jewish General Hospital, McGill University, 4333 C^ote-Sainte-Catherine, Montreal, QC H3T 1E4,
Canada
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 A. POTES ET AL.
symptoms with their use, such as exacerbation of acute psychosis
(Allen et al., 2006), have been recently addressed by researchers
exploring mindfulness in psychotic disorders. Such reports high-
light that mindfulness approaches seem to benefit people with
psychosis alongside currently recommended interventions (CBT,
family interventions, etc.) (Aust & Bradshaw, 2016), report low
attrition rates in the majority of trials (Khoury et al., 2013), are
considered acceptable to a difficult to engage population (Killaspy
et al., 2006), can be safely administered with no adverse effects if
adapted to the needs of the clients supporting Gaudiano and
Herbert (2006)’s work, and importantly, suggest that future trials
involve evaluation research to offer service user broader options
of treatment (Aust & Bradshaw, 2016). Moreover, researchers have
also claimed that mindfulness-based interventions may be specif-
ically useful in treating negative symptoms of psychosis and have
mentioned the importance of acceptance and compassion as
complementary strategies to optimise clinical effects (Khoury
et al., 2013). Aside from psychotic disorders, a review from 2012
also stated that mindfulness interventions provides benefits for
people experiencing SPMI as suitable to impact distress related to
symptoms and internalised stigma; but reported significant cav-
eats related to methological issues, lack of consensus of oper-
ational definitions of mindfulness across the literature, unclear
examinations of change mechanisms underlying mindfulness, as
well as on exploring cognitive functioning (Davis & Kurzban,
2012). In light with this, the goal of this review is to summarise
the current state of research on mindfulness-based therapies in
treating patients experiencing SPMI, given the importance to
examine the current reality of mindfulness-based interventions as
therapy adjunct to SPMI.
Methods
Literature search
A literature search was undertaken using MEDLINE, PsychINFO
and EMBASE databases, as well as references of retrieved articles.
The search included papers published up to August 2017. The
search strategy was not limited by language but was conducted
using English-language search terms. The following search strat-
egy was used: ((‘psychosis’ OR ‘schizophrenia’ OR ‘bipolar disorder’
OR ‘inpatient psychiatry’ OR ‘severe mental illness’)) AND
(‘mindful
’ OR ‘mindfulness’).
Study selection
In August 2017, abstracts were scanned for eligibility, after which
the full texts of relevant articles were thoroughly reviewed for
inclusion. Acceptable studies had to (1) investigate the efficacy of
a mindfulness-based intervention for adult patients suffering from
severe and persistent mental illness (SPMI), (2) provide quantita-
tive data supported by statistical methodology, (3) involve
patients (whether hospitalised or not) with acute symptoms (e.g.,
psychosis, acute manic or depressive phases of bipolar disorder,
or concurrent hospitalisation for the primary disorder). Exclusion
criteria were the following: (1) qualitative reports, (2) studies inves-
tigating non-psychiatric samples as the target group, (3) studies
investigating patient’s baseline measures on mindfulness but no
intervention effects, (4) studies providing indirect interventions
(e.g., training health care providers in mindfulness, rather than the
patients themselves), (5) acceptance or compassion-based thera-
pies, (6) case reports and case series, (7) literature reviews and
meta-analyses and (8) abstracts which were potentially eligible
but full-text articles were not available in English.
Outcome measures
The main considered outcome measures were feasibility and
safety of the conducted interventions, pre/post-intervention meas-
ures of psychiatric symptoms, and, for controlled studies, inter-
group differences in measures of psychiatric symptoms.
Results
Search results
The original search identified 557 abstracts. Preliminary scanning
resulted in 121 abstracts considered for inclusion. Most of the
excluded articles upon preliminary review were either entirely
unrelated to the topic or were clearly reviews and opinion pieces.
Of the articles included for further screening, 51 were literature
reviews and opinion articles, nine were qualitative studies, 21
involved patients with insufficient severity of symptoms, 22 did
not investigate the direct results of mindfulness interventions, one
was an extension of previously reported preliminary results, two
did not have enough data for statistical analysis, one was a non-
peer-reviewed PhD thesis with no statistical analysis and one
potentially eligible full text was not available in English. This left
14 studies for inclusion in the present review (summarised in
Table 1).
Characteristics of selected studies
Sample population
All involved patients were diagnosed with a psychotic disorder as
per DSM criteria and had active psychotic symptoms. Four studies
had participants with recent-onset psychotic disorder, diagnosed
in the context of first/early-onset psychosis intervention services
(Khoury, Lecomte, Comtois, & Nicole, 2015; Samson & Mallindine,
2014; Tong et al., 2015; van der Valk, van de Waerdt, Meijer, van
den Hout, & de Haan, 2013). One study included participants with
subjectively distressing and unremitting psychosis for 2 years or
more, all of which had a diagnosis of paranoid schizophrenia or
schizoaffective disorder (Chadwick, Taylor, & Abba, 2005). Three
others also selected participants with a diagnosis of schizophrenia
or its subtypes; one of which patients were in a vocational
rehabilitation program (Davis et al., 2015), one including patients
with schizophreniform or delusional disorders (Langer, Cangas,
Salcedo, & Fuentes, 2012) and one including outpatient patients
(Wang, Chien, Yip, & Karatzias, 2016). Five studies selected patients
with psychotic disorders without mentioning patients’ specific
diagnoses; one of which included patients hearing distressing voi-
ces for at least 6 months (Chadwick, Hughes, Russell, Russell, &
Dagnan, 2009), another included veterans with psychotic disorders
(Tabak & Granholm, 2014), another included participants with a
psychotic illness recruited via the Internet (Moritz et al., 2015),
another included psychiatric inpatients (Nikolitch et al., 2016) and
another selected patients with schizophrenia who were visiting
outpatient clinics (Chien & Thompson, 2014). Apart from patients
with a psychotic disorder, one study included patients with psych-
otic or bipolar disorders (Randal, Bucci, Morera, Barrett, & Pratt,
2015). Sample sizes ranged from 8 (Samson & Mallindine, 2014) to
107 (Chien & Thompson, 2014).
Study design
Seven studies were randomised control trials (RCT) (Chadwick et al.,
2009; Chien & Thompson, 2014; Davis et al., 2015; Langer et al.,
2012; Moritz et al., 2015; Randal et al., 2015; Wang et al., 2016).
Table 1. Summary of studies included.
Reference
number Study authors Design Country Study population
1 Chadwick et al. Prospective England, (11) Participants (M age
(2005). Southampton ¼33.1; SD¼ 3.9) with
subjectively distressing
unremitting psychosis of
2 years, who attended
one of four mindfulness
groups. Diagnosis: DSM
criteria for paranoid
schizophrenia (9) and
schizoaffective disorder
(2). Number of years. in
contact with psychiatric
services: M ¼ 6.9.
2 Chadwick et al. Feasibility trial; RCT England, London (22) > 18 years old (M ¼ 41.6;
(2009) SD¼ 8.1), active psychotic
symptoms (distressing
voice for at least 6
months), under care of
secondary mental health
service. Mean duration of
illness¼ 17.7 years (SD
9.8)
3 Langer et al. (2012) RCT Spain, Almeria (19) Participants had active
psychotic symptoms and
a diagnosis of schizophre-
nia, schizophreniform dis-
order, schizoaffective
disorder, or delusional dis-
order (M age ¼34.7; SD¼
8.2; 51.1. % male)
4 van der Valk et al. Prospective Amsterdam, (13) participants (M age
(2013) Netherlands ¼31.8; SD¼ 5.2), recent-
onset (<6 months) psych-
osis, 5–7 participants in
each mindfulness group
5 Chien and RCT China, Hong Kong (36) Patients diagnoses with
Thompson schizophrenia visiting out-
(2014) patient clinics. Placed
into: intervention (M age
¼25.1; SD ¼6.8; 20
males), (36) conventional
psychoeducation (M age
¼25.8; SD ¼7.9; 21
males), (35) routine out-
patient care (M age
¼26.0; SD ¼8.5; 20
males)
6 Samson and Prospective England, London (8) Participants in an early
Mallindine intervention in psychosis
(2014) service -diagnosed with
recent-onset psychotic
disorder (M age ¼29
years, 7 males), number
of yrs. in contact with
psychiatric services:
M ¼ 8.8 months
Frequency and Duration
90-min sessions (6 weeks)
5 weeks of group-based
mindfulness practice plus
5 weeks of home practice
8 weeks
Twice-a-week (8 sessions)
12 every two weeks (2-hour
long session)- 6-month
program
Weekly 90-min sessions (8
weeks)
(n) Intervention Group
(11) Mindfulness; up to 6-par-
ticipant groups. Guided
body scan (3 minutes) and
mindfulness of the breath,
two 10-min guided sit-
tings per session, 15-min
break
(11) Adapted mindfulness
training for psychosis
(Chadwick, 2006) þ TAU;
Two 10-minute mindful-
ness meditations per ses-
sion, plus reflective group
discussion
(7) MBCT with adaptations for
psychosis (Chadwick,
2006)
(13) 3-min breathing medita-
tion, 10-min body scan,
walking meditation and
meditative yoga
(36) Mindfulness-based psy-
choeducation (designed
by author)
(8) Modified mindfulness-
based therapy with short
guided meditations
(n) Control Group Primary outcome measure(s) Main findings
N/A CORE Significant reduction in CORE
score; Z¼-2.655, p¼.008
(11) Wait-list and TAU CORE Feasibility analysis: interven-
tion beneficial but no sin-
gle measure was
conclusive; CORE change
NSD between control and
intervention group on
psychotic features
(p>.05); Power analysis:
groups of 23 needed to
detect difference
(11) Wait-list control CGI-SCH NSD in clinical measures on
CGI; secondary measures
of mindful response to
distressing thoughts and
images: higher mindful
response in intervention
group, t ¼ 2.445, p¼.028
N/A SCL-90 PANSS Feasibility: positively per-
ceived with no worsening
of symptoms (70% reten-
tion); SCL-90: significant
decreases in psycho neur-
oticism (p¼.025) and
agoraphobia scales
(p¼.028); NSD on PANSS
1. (36) Conventional psycho- Baseline, week 1, 12 months Reduction in BPRS (F ¼ 4.36,
education. and 24 months: p¼.005), increase in SLOF
2. (35) Routine outpatient BPRS (F ¼ 4.98, p¼.004) and
care SLOF ITAQ (F ¼ 6.52, p¼.001),
SSQ6 decrease in duration of
ITAQ readmissions (F ¼ 4.80,
p¼.004). No NSD signifi-
cant difference on SSQ6
(p¼.13) and readmissions
to hospital (p ¼ 0.096).
Significant differences on
SLOF at times 2–4 on
self-maintenance, social
skills functioning, and
community functioning
(p¼ <.005). TAU reported
negative outcomes over
time and significant
reductions in the SLOF
and BPRS at time 3
N/A CORE NSD on CORE. No reports on
SMQ adverse effects
DASS
Effect size
N/A
CORE and measures of psych-
otic features (thoughts
and images d ¼ 0.86, voi-
ces d ¼ 0.47; beliefs about
voices, d ¼ 0.29; auditory
hallucinations, d ¼ 0.26;
paranoia, d ¼ 0.12)
GSI (intervention group,
d ¼ 1.17; WLC, d ¼ 0.335);
AAQII-acceptance and
action (intervention
group, d ¼ 0.010; WLC,
d ¼ 0.16), SQM-mindful-
ness (intervention group,
d ¼ 1.31; WLC, d ¼ 0.20)
SCL-90 and neuroticism
(d ¼ 0.44), anxiety
(d ¼ 0.28), agoraphobia
(d ¼ 0.43), depression
(d ¼ 0.26), somatisation
(d ¼ 0.21), insufficiency
(d ¼ 0.33), interpersonal
sensitivity (d ¼ 0.37), hos-
tility (d ¼ 0.14), sleeping
problems (d ¼ 0.32)
BPRS partial g2 (effect size
used in ANOVA) of 0.16,
SLOF g2¼ 0.19, ITAQ g2¼
0.28 and SSQ6 g2¼0.05.
Duration of readmissions
g2 ¼ 0.16 and readmis-
sions g2¼0.09
CORE partial g2 (effect size
used in ANOVA) of 0.22,
DASS partial g2¼ 0.34,
SMQ partial g2¼ 0.33
(continued)
Table 1. Continued
Reference
number Study authors Design Country Study population
7 Tabak and Prospective USA, Los Angeles (10) Veterans with psychotic
Granholm disorders (M age ¼45.10;
(2014)9 SD ¼14.99, 9 males)
8 Davis et al. (2015) RCT USA, Indianapolis (34) Participants with schizo-
phrenia or schizoaffective
disorder in a vocational
rehabilitation program (M
age¼ 53.2; SD 6.1, 17
males/1 females, 4.1
years, SD 2.6 lifetime hos-
pitalisations- for interven-
tion group)
9 Khoury et al. (2015) Prospective Canada, Montreal (12) Participants from a first
psychotic episode clinic
(M age¼ 29.08; SD 8.13;
8 males; mean age of first
visit to a psychiatrist¼
21.92; SD 5.92).
10 Moritz et al. (2015) RCT Germany, Hamburg (90) participants with a diag-
nosis of psychotic illness
were recruited via the
internet
11 Randal et al. (2015) Prospective England, (13) Participants with psych-
Manchester otic (majority) or bipolar
disorder (M age¼ 37.6;
SD 10.5; 11 males; years
since first episode¼ 11.5;
SD 3–25)
12 Tong et al. (2015) Prospective China, Hong Kong Participants with at least 5
years of inset of illness
(early psychosis), present-
ing mild depressive and
anxiety symptoms (M
age¼ 47; SD 12.17; 4
men, mean duration since
onset¼ 2.89 years; SD
0.53).
Frequency and Duration
6 weekly individual sessions
(6 weeks)
Twice-weekly, 90 min sessions
(16 weeks)
60–75 min/session (8 weeks)
6 weeks
2 h once a week (8 weeks)
1.5 h/week (7 weeks devel-
oped by authors)
(n) Intervention Group
Mindfulness training adapted
from existing mindful-
ness-based therapies
(Stahl
and Goldstein, 2010)
(18) Mindfulness Intervention
for rehabilitation and
recovery in Schizophrenia
(MIRRORS) adaptation of
MBSR (Davis et al., 2015)
Compassion, acceptance,
mindfulness (CAM-devel-
oped by the authors):
mindful eating and
breathing exercises, 15-
min mindfulness medita-
tion practice, emotion-
regulation strategies
(52) Self-help manual for
mindful breathing, body
scan, mindfulness in
everyday life, etc.
MBCT with some modifica-
tions for psychosis
(reduced length of medi-
tation exercises to
10–15 min, frequent guid-
ance, references to psych-
otic experiences)
Three trials of mindfulness-
based intervention pro-
gram (MBIP), low-intensity
practices
(n) Control Group Primary outcome measure(s) Main findings Effect size
N/A MCCB Significant pre/post differen- Large effects in processing
MATRICS ces on working memory speed (d ¼ 0.61) and
BDI-II (p¼.03). Large effect working memory
PSYRATS working memory (0.84). (d ¼ 0.84). Medium effects
Most participants prac- were found for verbal and
ticed mindfulness 5–7 visual learning (0.32 and
times/week (M ¼ 8.61 min; 0.30), and small effects
SD ¼4.29; range were found for attention/
¼0–13.81). Significant vigilance (d ¼ 0.47-small
results on self-reported to medium) and reason-
mean stress levels ing/problem solving
(p ¼ .03) and mean mood (d ¼ 0.20). On clinical
ratings (p ¼ .03) measures, participants
reported large decreases
in anxiety (d ¼ 0.66),
depression (d ¼ 0.73), and
conviction in and pre-
occupation with delusions
(d ¼ 0.82)
(16) Support-group (Intensive Baseline, mid-intervention (8 Significant increases in inter- Weeks of work (d ¼ 0.65), h
support) control weeks), intervention end vention group on hours of work (d ¼ 0.76), treat-
(12 weeks) and follow-up of work (p¼.04), and total ment end WBI (d ¼ 0.82)
(24 weeks): WBI score at treatment
PANSS end (p¼.023), as well as
WBI WBI Work Quality
CAS (p¼.021) and personal
MFS presentation (p¼.036)
CSQ-8 subscales
N/A Baseline, post-treatment, 3- Significant differences in posi- Post-intervention: positive
month follow-up meas- tive emotions on CERQ symptoms (d ¼ 0.36).
ures for: (p¼.007) at 3-month fol- Follow-up: depression
BPRS-expanded, SFS low-up anxiety (d ¼ 0.68). Three-
CERQ month follow-up: anxiety
PDMMS (d ¼ 0.92), depression
FMI (d ¼ 0.91), self-neglect
BCIS (d ¼ 0.71) and somatic
concerns (d ¼ 0.50)
(38) Progressive muscle relax- At baseline and 6 weeks: No significant differences in Depression (d ¼ 0.89), OCD
ation (PMR) self-help manual POD outcome measures. (d ¼ 0.59)
OCI-R Participants reported pro-
CES-D grams were suitable for
CAPE self-administration and
useful
N/A At 2 points before interven- No significant changes in Constructs of ideal self and
tion and 2 points after symptom scales. In reper- self as recovered from
intervention: tory grid: pre-post dis- psychosis (d¼-0.73)
CORE tance between the
FFMQ constructs of ideal self
PSYRATS BAVQ-R BCSS and self as recovered
QPR from psychosis was sig-
nificantly shortened
(p¼.045). Significant
change in total QPR score
(p¼.05) and in the 'act
with awareness' subscale
of the FFMQ (p¼.023).
Constructs of ideal self
and self as recovered
from psychosis (d¼-0.73)
N/A PANSS Acceptable and feasible inter- Anxiety G12 (d ¼ 0.51); DASS-
CDSS vention. Significant 21-A (d ¼ 0.24).
DASS-21-D improvements in depres-
BDI- II sive symptoms (BDI-II)
DASS-21- PANSS Item G6 (p¼.034), DASS-21-D
(anxiety) (p¼.031); quality of life-
SF-12 (p¼.012); mindful-
ness FFMQ-observe
(p¼.012) and acting with
awareness (p¼.018);
PANSS total (p¼.017) and
general psychopathology
(p¼.017). No difference
on anxiety measures
(continued)
Table 1. Continued
Reference
number Study authors Design Country Study population Frequency and Duration (n) Intervention Group (n) Control Group Primary outcome measure(s) Main findings Effect size
13 Nikolitch et al. Retrospective Montreal and (40) Psychiatric inpatients One session of a 10-min Interventions included N/A Suitability for and tolerating The intervention was well tol- N/A
(2016) Toronto, Canada mindfulness-oriented group Mindful eating, TaiChi and the brief group mindful- erated (92.5%) and 50%
intervention between January body scan ness oriented interven- of patients met both the
and March 2014 tion, defined as improved suitability and tolerability
pre–post self-reported criteria. Tai chi was the
mood scores and tolerat- most suitable/tolerable
ing the 10-min interven- compared with body scan
tion until its completion and mindful eating
(76.5% versus 35.7% ver-
sus 22.2%, Fisher’s exact
p¼ .01, Bonferroni
p<.05).
14 Wang et al. (2016) RCT Hong Kong, China (138) Outpatients with schizo- A mindfulness-based psycho- A mindfulness-based psycho- Conventional psychoeduca- SLOF and average number MPGP participants reported N/A
phrenia or its subtypes education group program education group program tion group program (CPGP) and length of patients' greater reductions in
(CPGP) (12 two-h sessions (MPGP). and Treatment as usual (TAU) rehospitalisations in the psychotic symptoms
every 2 weeks) past 6 months (p¼.003) and length/dur-
ation of rehospitalisations
(p¼.005) at 6-month fol-
low-up. Patients in the
MPGP group also had
greater improvements in
their illness/treatment
(p¼.00008) and level of
functioning (p¼.002) than
the CPGP and TAU alone
at the 1-week and 6-
month follow-up
SSQ6: Six-item Social Support Questionnaire; BCIS: Beck Cognitive Insight Scale; BDI-II: Beck Depression Inventory-II; BCSS: Brief Core Schema Scales; BPRS: Brief Psychiatric Rating Scale; BAVQ-R: Beliefs About Voices Questionnaire-
Revised; BPRS-expanded: Brief Psychiatric Rating Scale Expanded; CDSS (depression); CES-D: Center for Epidemiologic Studies-Depression Scale; CAS: Change Assessment Scale; CSQ-8: Client-Satisfaction Questionnaire; CORE: Clinical
Outcomes in Routine Evaluation; CGI-SCH: Clinical Global Impression-Schizophrenia Scale; CERQ: Cognitive Emotion Regulation Questionnaire; CAPE: Community Assessment of Psychic Experiences Scale; DASS: Depression Anxiety
Stress Scale; FFMQ: Five Facet Mindfulness Questionnaire; FMI: Freiburg Mindfulness Inventory; ITAQ: Insight and Treatment Attitudes Questionnaire; MCCB: MATRICS Consensus Cognitive Battery; MBCT: Mindfulness-based Cognitive
Therapy; MFS: Mindfulness Fidelity Scale; NSD: non-significant differences (p > .05); OCI-R: Obsessive–Compulsive Inventory-Revised; PODS: Paranoia-Obsession–Depression Scale; PANSS: Paranoia Checklist; Positive and Negative
Symptom Scale; PDMMS: Psychological Distress Manifestation Measure Scale; PSYRATS: Psychotic Symptoms Rating Scale; QPR: Questionnaire about the Process of Recovery; Repertory Grid (measuring constructs of self); SFS: Social
Functioning Scale; SLOF: Specific Levels of Functioning Scale; SMQ: Southampton Mindfulness Questionnaire; SCL-90: Symptom Checklist-90; WBI: Work Behavior Inventory.
6 A. POTES ET AL.
Control comparison groups involved two studies using two con-
trol groups including a routine outpatient care and conventional
psycho-education (Chien & Thompson, 2014) and a conventional
psychoeducation group program (CPGP) and Treatment as usual
(TAU) (Wang et al., 2016), study using a support group (Davis
et al., 2015), a study using a progressive muscle relaxation (PMR)
self-help manual (Moritz et al., 2015), a study using conventional
psycho-education (Chien & Thompson, 2014) and a study using
healthy controls (Tabak & Granholm, 2014). The remaining studies
use treatment as usual (TAU) and wait-list control conditions as
comparison groups. As per the remaining eight studies included
in this review, seven were prospective (Chadwick et al., 2005;
Khoury et al., 2015; Randal et al., 2015; Samson & Mallindine,
2014; Tabak & Granholm, 2014; Tong et al., 2015; van der Valk
et al., 2013) and one was retrospective (Nikolitch et al., 2016).
Type of mindfulness intervention
As suggested by Chadwick et al. (2005), eight studies used at least
some modifications of mindfulness training for psychosis
(Chadwick et al., 2005, 2009; Chien & Thompson, 2014; Khoury
et al., 2015; Langer et al., 2012; Nikolitch et al., 2016; Randal et al.,
2015; Wang et al., 2016). These modifications included limiting the
duration of guided meditations to 10–15 min with frequent guid-
ance throughout the meditations to prevent participants from
becoming engaged with psychotic experiences. Five studies used
their own modified structured mindfulness-based therapy (Randal
et al., 2015; Samson & Mallindine, 2014; Tabak & Granholm, 2014;
Tong et al., 2015; van der Valk et al., 2013). Two studies offered
mindfulness-based psychoeducation to patients with schizophre-
nia (Chien & Thompson, 2014; Wang et al., 2016), whereas another
study used self-help manuals of mindful activities (Moritz et al.,
2015).
Frequency of intervention delivery and follow-up measures
The number of sessions per study varied between 1 and 16 weeks,
and offered weekly, bi-weekly or sessions every 2 week. One study
used eight sessions, twice a week (van der Valk et al., 2013), while
another used 8-week, 2 h modified MBCT (Randal et al., 2015).
Most studies used 5–8 weekly sessions, with pre- and post-testing
measures taken within 2 weeks from intervention beginning and
end. One study completed follow-up measures at 12 and
24 months from baseline of a 6-month program (Chien &
Thompson, 2014). Similarly, one study conducted follow up meas-
ures at 24 months from baseline of a 4-month program (Davis
et al., 2015), whereas another one collected 3-month follow-up
measures from baseline of a 8-week program (Khoury et al., 2015).
One study only included data from participants who attended at
least one session (Chadwick et al., 2005) due to the small number
of participants overall (11 and 8), and variability of attendance.
Duration of sessions
Most sessions were 60 min long, with the exception of Samson
and Mallindine (2014), and Tong et al. (2015), who used 90-min
sessions of modified mindfulness-based therapy. Moreover, Chien
and Thompson (2014) and Randal et al. (2015), offered 2-h ses-
sions of mindfulness-based therapies.
Feasibility
All studies report that the interventions did not result in an
increase in psychotic experiences were well tolerated and had
generally positive response among participants in terms of suit-
ability and usefulness of the programs. For instance, Moritz et al.
(2015) showed no differences in outcome measures, yet partic-
ipants’ reported that programs were suitable for self-administra-
tion and benefitial to them.
Psychotic symptoms
Five out of six total RCTs explored psychotic symptoms. One RCT
reported a significant reduction in the Brief Psychiatric Rating
Scale (BPRS) and McEvoy’s Insight and Treatment Attitude
Questionnaire (ITAQ) scores (Chien & Thompson, 2014). They also
showed a decrease in duration of re-admissions and increased
scores in the Specific Level of Functioning Assessment Scale
(SLOF) and in the Mindfulness-based Psycho-education group
(n ¼ 36), compared with two control groups (conventional psycho-
education and routine outpatient care) of 36 and 35 participants,
respectively. In a three-arm RCT comparing a mindfulness-based
psychoeducation group program (MPGP), a conventional psycho-
education group program (CPGP) and Treatment as usual (TAU),
Wang et al. (2016) also reported greater reductions in psychotic
symptoms (p ¼ .003). Moreover, two other RCTs reported no sig-
nificant differences between the intervention and control groups
on psychotic features as measured by CORE (Chadwick et al.,
2009) and CGI-SCH (Langer et al., 2012). Still, Chadwick et al.
(2009) reported that a power analysis based on these data
required groups of 23 participants or more in each group to
detect significant differences, and their intervention and wait-list
control groups only had 11 participants in each arm. Similarly,
Langer et al. (2012) reported having higher mindful responses in
the intervention group, despite its small samples size (e.g., seven
participants in the intervention group and 11 in the wait-list con-
trol condition). The remaining RCTs did not report statistical sig-
nificant results (Davis et al., 2015; Moritz et al., 2015), and one did
not address measures of psychosis (Wang et al., 2016).
Six out of seven non-randomised (prospective) studies reported
a significant decrease in CORE scores post-intervention (Chadwick
et al., 2005), as well as in significant decreases in PANSS General
Psychopathology scores (Tong et al., 2015). Furthermore, five stud-
ies reported no significant differences pre-post intervention on
psychotic symptom rating scales (PANSS) (van der Valk et al.,
2013), CORE (Randal et al., 2015), BPRS (Khoury et al., 2015) and
PSYRATS (Randal et al., 2015; Tabak & Granholm, 2014). On
another study asking participants to state the degree of interfer-
ence of five psychotic symptoms on a scale of 0–100 at multiple
times during and after the intervention, the authors reported the
group mean and median before, during, and after the interven-
tion; a decrease of the scores as the intervention progressed was
reported, but without reaching statistical significance (Randal
et al., 2015). One study did not find statistical significant results
(Samson & Mallindine, 2014), and the one only retrospective study
did not address measures of psychosis (Nikolitch et al., 2016).
Other outcome measures
Five studies focused on outcomes other than measures of psych-
otic symptoms. Davis et al. (2015) reported that their Mindfulness
Intervention for Rehabilitation and Recovery in Schizophrenia
(MIRRORS) adapted from Mindfulness-Based Stress Reduction
(MBSR), resulted in significant increases on hours of work in the
intervention group, Work Behaviour Inventory (WBI) score at treat-
ment end, Work Quality, as well as Personal Presentation sub-
scales. Additionally, Randal et al. (2015) used repertory grids to
measure the participants’ construction of particular concepts (e.g.,

Self, Ideal Self and Self as Recovered from Psychosis) and found
that the pre-post intervention distance between the constructs of
Ideal Self and Self as Recovered from Psychosis was significantly
shortened, with a large effect size (d ¼ 0.73). The authors also
reported significant improvements in the Process of Recovery
Questionnaire (QPR) and in the ‘act with awareness’ subscale of
the Five Facet Mindfulness Questionnaire (FFMQ). Moreover, in
their non-randomised, uncontrolled, pilot study of 10 Veterans
with psychotic disorders, Tabak and Granholm (2014) reported
that measures of cognitive skills on the MATRICS Consensus
Cognitive Battery (MCCB) resulted in statistical significant results
with large effect sizes in working memory (d ¼ 0.84). Also, in a
non-randomised, uncontrolled, pilot study, Tong et al. (2015)
reported significant improvements in depressive symptoms, based
on the Beck Depression Inventory (BDI-II) and the Depression
Anxiety Stress scale – depression subscale (DASS-21-D) scores, but
no change in anxiety symptoms, as measured by the Positive and
Negative Symptom scale, the Item G2, and the Depression Anxiety
Stress scale – anxiety subscale (PANSS G2 and DASS-21-A). In
Wang et al. (2016)’s three-arm RCT, greater reductions in length/
duration of rehospitalisations (p ¼ .005) at 6-month follow-up were
observed, as well as greater improvements in their illness/treat-
ment (p ¼ 0.00008) and level of functioning (p ¼ .002) of MPGP
compared to CPGP and TAU, at the 1-week and 6-month follow-
up. Finally, Nikolitch et al. (2016)’s retrospective study, reported
the intervention to be well tolerated (92.5%), where 50% of
patients met both the suitability and tolerability criteria as defined
by the authors.
Discussion
Most studies that have examined mindfulness-based interventions
in SPMI report some reductions in measures of psychotic symp-
toms, despite not detecting statistically significant effects. This is
likely because of small sample sizes. However, statistically signifi-
cant improvements were consistently observed on measures of
quality of life, level of functioning, participant’s constructions of
the self, process recovery, acting with mindful awareness, cogni-
tive skills and depression symptoms. This suggests that mindful-
ness-based intervention can improve many areas of mental and
cognitive difficulties, as well as quality of life psychosocial func-
tioning. Larger clinical trials will likely be needed to definitively
assess whether mindfulness-based interventions can improve
psychotic symptoms.
Consistent with recent reviews (Davis & Kurzban, 2012; Khoury
et al., 2013), we found that shorter tailored mindfulness-based
interventions in SPMI were found to be feasible and acceptable.
There were no reports onacute exacerbation of symptoms, con-
trary to previous beliefs stating that mindfulness techniques (as
an independent component of therapy) may worsen psychotic
symptoms and distress in severe mental illness (Academic
Mindfulness Interest Group M and Academic Mindfulness Interest
Group M, 2006). The literature on mindfulness interventions in
patients with SPMI is limited and cautiously advancing. Current
SPMI constructs limits our understand of the literature available
on this fragile patient population (Ruggeri et al., 2000). In this
review, only one study addressed mindfulness therapies of psych-
otic and bipolar patients (Nikolitch et al., 2016). Given the vast
majority of studies considered SPMI patients as those primarily
diagnoses with psychotic disorders, this stresses and important
gap in the literature, as SPMI involves all chronic patients in need
of mental health treatment, with impaired functioning and dys-
functional capacities for daily living, which also represents the
characteristics of most bipolar patients (Administration SAaMHS,
INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 7
1999; Anthony, 1993). In this vein, results from this review portray
a very small number of studies with rigorous methodological
designs, identifying only six RCTs. Despite having a control condi-
tion, only three studies used an active controlled condition includ-
ing conventional psychoeducation (Chien & Thompson, 2014;
Wang et al., 2016), a support group (Davis et al., 2015) and a self-
manual (Moritz et al., 2015). The remaining RCTs which used wait-
lists did not truly address the multiple confounding factors inher-
ent in designing psychotherapy trials (e.g., the effect of being in a
group of people who meet regularly, participating in facilitated
discussions, receiving feedback on psychotic symptoms and the
nature of psychotic experiences and illness – all of which may
impact insight, social functioning and level of psychotic symp-
toms) (MacCoon et al., 2012). It also remains unclear whether the
use of active control conditions are actually comparable to mind-
fulness-based interventions. It is, therefore, suggested that future
studies address the use of manualised Health-Enhancement
Program (HEP) as an active control condition for mindfulness-
based interventions, given it has been previously designed and
used for this purpose, controlling for several non-specific factors
found in a mindfulness meditation group (MacCoon et al., 2012).
Another important limitation relies on measures of long-term fol-
low-up accounting for endurance effects. Only one study followed
participants for 3 months after the end of the intervention (Khoury
et al., 2015) and another used a 6-month follow-up (Wang et al.,
2016); all others stopped data collection shortly after the end of
the program. Finally, as mentioned by Coronado-Montoya et al.
(2016), publication bias may still be significant in studies on mind-
fulness-based interventions, where up to 62% of registered trials
on mindfulness interventions remain unpublished 30 months after
registration and those with positive effects may be actually over-
stating what would occur in practice.
The present review also emphasises the importance of using a
procedure or set of modifications for mindfulness-based therapy
with patients undergoing psychotic symptoms. For instance, keep-
ing meditation brief (10–15 min) and guidance frequent, while
facilitating the discussion of psychotic experiences, has been ori-
ginally suggested by pioneering researchers of mindfulness-based
interventions for psychosis (Chadwick et al., 2005). Still, given the
unclear diversity of operational definitions around the term
‘mindfulness’, the present review has considered mindfulness
therapies separate from ‘acceptance’ and ‘compassion’ interven-
tions, such as acceptance and commitment therapy (Hayes,
Strosahl, & Wilson, 1999) and compassion-focused therapy (Gilbert
2001). These newer third-wave therapies have also been sug-
gested as novel approaches to modified mindfulness therapies in
psychosis (Aust & Bradshaw, 2016; Khoury et al., 2013), and have
been recommended as optimistic therapy venues in this patient
population (Cramer, Lauche, Haller, Langhorst, & Dobos, 2016;
DiGiacomo, Moll, MacDermid, & Law, 2016). It is, therefore, recom-
mended that future research states clearer operational definitions
around the term ‘mindfulness’, so that researchers may thoroughly
address the effectiveness of mindfulness, and more recent com-
passion and acceptance-based interventions, not only as treat-
ment adjuncts of psychosis but to all-encompassing patients
suffering from SPMI.
In conclusion, the present review suggests that mindfulness-
based therapy for patients with SPMI are suggested to be clinic-
ally effective in decreasing psychotic symptoms despite non-
observable statistical results. Moreover, improvements in symp-
toms of depression, cognitive skills, gains in mindful awareness, as
well as psycho-social and vocational factors were also importantly
noted. These interventions were also found to be feasible and
well tolerated by patients, as elucidated by no presence of
8 A. POTES ET AL.
adverse events. Future studies using methodological rigor (e.g.,
those using RCTs, including sufficient statistical sample size power,
a manualised active control condition such as HEP, evaluating fol-
low-up periods) and including other psychiatric patient population
which also represent SPMI (e.g., bipolar) are urgently needed to
bring to light the true potential benefits of mindfulness-based
interventions in this neglected patient population. In addition,
future studies examining what components of mindfulness-based
therapies cause the most change would be interesting to explore
the mechanisms of mindfulness. It is, therefore, recommended
using qualitative methodology to help elucidate group effects as
a result of social context (e.g., people interactions within a group
setting) compared with mindfulness components (e.g., focused
attention, non-judgemental awareness and compassion for
others).
Acknowledgements
None.
Disclosure statement
There are no disclosures of interest to declare.
ORCID
Angela Potes http://orcid.org/0000-0003-3780-657X
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