Improve Well-Being with a Smartphone Mindfulness App

Improve Well-Being with a Smartphone Mindfulness App

 

By John M. de Castro, Ph.D.

 

“What do you do when you can’t afford therapy but are struggling to handle your mental illness alone? You could download an app. In recent years, there’s been a proliferation of mental health apps available to smartphone users. These reasonably-priced, or most often free, mental health apps offer a wealth of resources that make therapeutic techniques more accessible, portable, and cost-effective.” – Jessica Truchel

 

Mindfulness training has been shown through extensive research to be effective in improving physical and psychological health. The vast majority of the mindfulness training techniques, however, require a trained teacher. This results in costs that many college students can’t afford. In addition, the participants must be available to attend multiple sessions at particular scheduled times that may or may not be compatible with their busy college schedules and at locations that may not be convenient. As an alternative, Apps for smartphones have been developed. These have tremendous advantages in decreasing costs, making training schedules much more flexible, and eliminating the need to go repeatedly to specific locations. But the question arises as to the effectiveness of these Apps in inducing mindfulness and improving psychological health in college students.

 

In today’s Research News article “Intermittent mindfulness practice can be beneficial, and daily practice can be harmful. An in depth, mixed methods study of the “Calm” app’s (mostly positive) effects.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928287/?report=classic), Clarke and Draper recruited healthy college students and had them complete a 7-day mindfulness training with the “Calm” smartphone app. The program consists of once a day 10-minute trainings. The students completed measures before and after training of mindfulness, well-being, and self-efficacy.

 

They found that after the 7-day training there were significant increases in mindfulness, well-being, and self-efficacy. They report that students who only completed 1 or 2 of the 7 “Calm” modules did not obtain the benefits. It appears that completing 3 or more of the modules is necessary to improve the students’ psychological health.

 

This is a brief study without a comparison condition and so the results must be interpreted cautiously. But, a number of prior studies have demonstrated that mindfulness trainings with smartphone apps are effective in improving well-being. In addition, the students who did not complete a significant number of the 7 training modules did not show improvements in psychological health. So, it would appear that the use of smartphone apps are a convenient method to teach mindfulness and this can have a significant impact on the psychological health of the users.

 

So, improve well-being with a smartphone mindfulness app.

 

Mental health apps can be effective in making therapy more accessible, efficient, and portable.” – Mary Let

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Clarke, J., & Draper, S. (2019). Intermittent mindfulness practice can be beneficial, and daily practice can be harmful. An in depth, mixed methods study of the “Calm” app’s (mostly positive) effects. Internet interventions, 19, 100293. doi:10.1016/j.invent.2019.100293

 

Abstract

Objectives

Despite a weak evidence base, daily use of mindfulness-based self-help smartphone applications (apps) is said to promote wellbeing. However, many do not use these apps in the way that app developers and mindfulness proponents recommend. We sought to determine whether the “Calm” app works, and whether it does so even when it is used intermittently.

Methods

Employing a mixed-methods design, we recruited a self-selected sample of 269 students from a Scottish university (81% female, 84% white, mean age 23.89) to engage with a seven-day introductory mindfulness course, delivered using Calm, currently one of the most popular, yet under-researched, apps.

Results

Daily course engagement was associated with significant gains in wellbeing (p ≤.001, d = 0.42), trait mindfulness (p ≤.001, d = 0.50) and self-efficacy (p ≤.014, d = 0.21). Intermittent course engagement was also associated with significant gains in wellbeing (p ≤.028, d = 0.34), trait mindfulness (p ≤.010, d = 0.47) and self-efficacy (p ≤.028, d = 0.32). This study is therefore the first to demonstrate that the Calm app is associated with positive mental health outcomes. It also shows that regular use is not essential. A thematic analysis of qualitative data supported these quantitative findings. However it also revealed that some participants had negative experiences with the app.

Conclusions for practice

Mindfulness-based self-help apps such as Calm have the potential to both enhance and diminish users’ wellbeing. Intermittent mindfulness practice can lead to tangible benefits. Therefore, mindfulness proponents should not recommend daily practice, should increase awareness of the potential for negative outcomes, and resist the idea that mindfulness practice works for everyone. Developers of mindfulness apps ought to make specific features customisable in order to enhance their effectiveness.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928287/?report=classic

 

Mindfulness is Related to the Well-Being of First Year College Students

Mindfulness is Related to the Well-Being of First Year College Students

 

By John M. de Castro, Ph.D.

 

Being mindful makes it easier to savor the pleasures in life as they occur, helps you become fully engaged in activities, and creates a greater capacity to deal with adverse events,” – Abby Fortin

 

In the modern world education is a key for success. Where a high school education was sufficient in previous generations, a college degree is now required to succeed in the new knowledge-based economies. There is a lot of pressure on university students to excel so that they can get the best jobs after graduation. This stress might in fact be counterproductive as the increased pressure can actually lead to stress and anxiety which can impede the student’s physical and mental health, well-being, and school performance.

 

Contemplative practices including meditationmindfulness training, and yoga practice have been shown to reduce the psychological and physiological responses to stress. Indeed, these practices have been found to reduce stress and improve psychological health in college students. But these techniques have been primarily tested with western populations and may not be sensitive to the unique situations, cultures, and education levels of diverse populations. Hence, there is a need to investigate the relationships of mindfulness to psychological health with diverse populations. There are indications that mindfulness therapies may be effective in diverse populations. But there is a need for further investigation with different populations.

 

In today’s Research News article “Relationship Between Dispositional Mindfulness and Living Condition and the Well-Being of First-Year University Students in Japan.” (See summary below or view the full text of the study at: https://www.frontiersin.org/articles/10.3389/fpsyg.2019.02831/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1191386_69_Psycho_20191224_arts_A), Irie and colleagues had first year Japanese college students complete questionnaires measuring mindfulness, well-being, living conditions and daily stressors. These data were then subjected to hierarchical multivariate regression analysis.

 

They found that the greater the number of daily life stressors, the lower the well-being of the first-year college students and the higher the levels of mindfulness the greater the well-being of the students. In addition, they found that for students low in mindfulness, living alone decreased well-being. But for students high in mindfulness, living alone had no effect on well-being.

 

It has been well established with multiple groups that mindfulness improves well-being. The present findings suggest that mindfulness is positively related to well-being in first-year Japanese college students. This further expands the generalizability of the mindfulness-well-being relationship. In addition, the results suggest that mindfulness may protect the students from the deleterious effects of living alone, away from home, on the difficult psychological adjustments occurring during the transition to college. It is for future research to establish if mindfulness training may help students in their adjustment to college life.

 

So, mindfulness is related to the well-being of first year college students.

 

mindfulness training can improve the mental health of university students. The finding is important as recent evidence suggests university students are more likely to develop mental health problems when compared with the general population.” – Rick Nauert

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Irie T and Yokomitsu K (2019) Relationship Between Dispositional Mindfulness and Living Condition and the Well-Being of First-Year University Students in Japan. Front. Psychol. 10:2831. doi: 10.3389/fpsyg.2019.02831

 

The present study was conducted to examine how dispositional mindfulness and living conditions are related to well-being among first-year university students in Japan. Participants were 262 Japanese first-year students (156 females and 106 males; Mage = 18.77 years, SDage = 0.85). Dispositional mindfulness was measured using the Mindful Attention Awareness Scale (MAAS), and living condition was operationalized as living at home or living alone after having left their home. Hierarchical multivariate regression analysis was used to analyze whether the factors of living condition and dispositional mindfulness had predictive effects on well-being. The results showed that dispositional mindfulness positively correlated with well-being in first-year university students; however, living condition had no significant correlation. On the other hand, the interaction between living condition and dispositional mindfulness significantly correlated with well-being. Simple slope analysis revealed that higher levels of dispositional mindfulness had a protective effect in the relationship between living condition and well-being. These results suggest that an intervention to promote dispositional mindfulness could be effective in protecting the well-being of first-year university students, especially for those who have left their home and are living alone. Further research will be necessary to examine, longitudinally, how mental health changes depending on the level of dispositional mindfulness of first-year university students.

https://www.frontiersin.org/articles/10.3389/fpsyg.2019.02831/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1191386_69_Psycho_20191224_arts_A

 

Increase Equanimity and Insight Thereby Increasing Well-Being with Meditation

Increase Equanimity and Insight Thereby Increasing Well-Being with Meditation

 

By John M. de Castro, Ph.D.

 

“Equanimity is a wonderful quality, a spaciousness and balance of heart. Although it grows naturally with our meditation practice, equanimity can also be cultivated in the same systematic way as mindfulness or compassion. We can feel this possibility of balance in our hearts in the midst of life when we recognize that life is not in our control.” – Insight Timer

 

Over the last several decades, research and anecdotal experiences have accumulated an impressive evidential case that the development of mindfulness has positive benefits for the individual’s mental, physical, and spiritual life. Mindfulness appears to be beneficial both for healthy people and for people suffering from a myriad of illnesses. It appears to be beneficial across ages, from children to the elderly. And it appears to be beneficial across genders, personalities, race, and ethnicity. The breadth and depth of benefits is unprecedented. There is no other treatment or practice that has been shown to come anyway near the range of mindfulness’ positive benefits.

 

In today’s Research News article “PROMISE: A Model of Insight and Equanimity as the Key Effects of Mindfulness Meditation.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6817944/), Eberth and colleagues investigate a proposed model of how meditation experience produces its benefits. They performed 2 studies. In the first, they interviewed experienced meditators asking them to identify and elaborate on things that they noticed had changed about themselves as a result of meditation.

 

From the reports they identified two principal factors that were altered. The first they labelled as equanimity which was a “reduced frequency and duration of emotional reactions, such as boredom, self-blame, anxiety, guilt, greed, envy, and many more.”  There is not a cessation of emotions but they “would recognize the emotion-evoking feature of the situation (e.g., praise or blame) but not experience a desire or resistance that would prolong or intensify the emotion.” The second factor they labelled as insight which were “convictional alterations that are accompanied by a subjective feeling of deep understanding and by changes in perception, judgment and/or behavior.” The interviews reflected that it was these changes that lead to positive changes in behavior and an alteration in the ideas of self.

 

In a second study they recruited experienced meditators and a control group of individuals who engaged in leisure time activities such as sorts, gardening, music, etc. They completed questionnaires measuring meditation practice, observation mode, including present moment attention and decentering; concept deactivation, including openness and acceptance; equanimity; insight; and life satisfaction.

 

They found that the meditators had significantly higher levels of all of the measured variables; observation mode, concept deactivation, equanimity, insight, and life satisfaction. They found that the greater the meditation experience the higher the levels of both facets of the observation mode, present moment attention and decentering, openness and acceptance, and insight. They then performed a path analysis which found that meditation practice leads to increases in observation mode and concept deactivation that in turn lead to increases in equanimity and insight that in turn lead to increased life satisfaction.

 

These results are very interesting and support a model of how meditation changes the underlying mental processing of the individual leading to positive effects on the individual’s lives. They postulated that meditation practice leads to becoming very observant of the present moment without becoming attached to it, and to becoming more open and accepting of events without conceptualizing them. These changes then alter the practitioner to better be able to regulate their emotions and to better understand the nature of reality. These alterations in the individual improves their ability to enjoy and appreciate their existence.

 

This is an interesting model that deserves further research attention. A better understanding of the mechanisms by which meditation practice improves the individual’s physical and mental health and their enjoyment of life can lead to improved and targeted meditation practices for the improvement of the individual’s physical, psychological, and spiritual well-being. This model is a good first step.

 

So, increase equanimity and insight thereby increasing well-being with meditation.

 

Insight Meditation is a simple and direct way to “see things as they are,” free from distortion.” – Josh Summers

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Eberth, J., Sedlmeier, P., & Schäfer, T. (2019). PROMISE: A Model of Insight and Equanimity as the Key Effects of Mindfulness Meditation. Frontiers in psychology, 10, 2389. doi:10.3389/fpsyg.2019.02389

 

Abstract

In a comprehensive meta-analysis on the effects of mindfulness meditation, Eberth and Sedlmeier (2012) identified a multitude of positive effects that covered a wide range of psychological variables, such as heightened mindfulness as measured through contemporary mindfulness scales, reduced negative emotions, increased positive emotions, changes in self-concept, enhanced attention, perception, and wellbeing, improved interpersonal abilities, and a reduction of negative personality traits. The present research aimed at developing and testing a comprehensive model explaining the wide range of mindfulness meditation effects and their temporal and causal relationships. In Study 1, interviews with meditators at different levels of experience were analyzed using a grounded theory procedure. The resulting model was triangulated and refined by concepts from both Western research and ancient Buddhist scriptures. The model developed highlights equanimity (reduction in emotional reactivity) and insight (alteration of cognitions) as the two key effects of mindfulness meditation that eventually lead to increased wellbeing. The model was pilot-tested with a large sample of meditators and non-meditators in Study 2. Data showed an acceptable fit with the model and indicated that meditators and non-meditators score significantly differently on the model’s core categories.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6817944/

 

Therapeutic Alliance is Important for Mindfulness Training to Improve the Psychological Health of Cancer Patients

Therapeutic Alliance is Important for Mindfulness Training to Improve the Psychological Health of Cancer Patients

 

By John M. de Castro, Ph.D.

 

“Both face-to-face and internet-based mindfulness-based cognitive therapy (MBCT) reduced psychological distress compared with usual care in patients with cancer.” – Matthew Stenger

 

Receiving a diagnosis of cancer has a huge impact on most people. Coping with the emotions and stress of a cancer diagnosis is a challenge and there are no simple treatments for these psychological sequelae of cancer diagnosis. But cancer diagnosis is not necessarily a death sentence. Over half of the people diagnosed with cancer are still alive 10 years later and this number is rapidly increasing. It is estimated that 15 million adults and children with a history of cancer are alive in the United States today. But, surviving cancer carries with it a number of problems. “Physical, emotional, and financial hardships often persist for years after diagnosis and treatment. Cancer survivors are also at greater risk for developing second cancers and other health conditions.” National Cancer Survivors Day.

 

Mindfulness training has been shown to help with cancer recovery and help to alleviate many of the residual physical and psychological symptoms, including stress,  sleep disturbance, and anxiety and depressionMindfulness-Based Cognitive Therapy (MBCT) consists of mindfulness training and Cognitive Behavioral Therapy (CBT). During therapy the patient is trained to investigate and alter aberrant thought patterns underlying their reactions to cancer. It is thought that the alliance between therapist and patient that is formed during treatment is important for the effectiveness of therapy. So, it would make sense to study the effectiveness of MBCT and the therapeutic alliance on the psychological distress of cancer patients.

 

In today’s Research News article “Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827984/), Bisseling and colleagues recruited adult cancer patients and randomly assigned them to either a wait list control condition or to receive Mindfulness-Based Cognitive Therapy (MBCT) in a group setting in 8 weekly 2.5 hour sessions with daily homework or online in 8 weekly practice sessions with therapist feedback emails. The participants were measured before and after training for anxiety, depression, mental well-being, and therapeutic alliance consisting of questions on “(1) how closely client and therapist agree on and are mutually engaged in the goals of treatment; (2) how closely client and therapist agree on how to reach the treatment goals; and (3) the degree of mutual trust, acceptance, and confidence between the client and therapist.

 

Of the Mindfulness-Based Cognitive Therapy (MBCT) participants significantly more dropped out of the online version (12.1%) than the group version(5.6%). The therapeutic alliance increased significantly over the intervention and did not differ between MBCT groups. They found that relative to baseline and the wait list control group MBCT training produced significant reductions in psychological distress and increases in mental well-being. In addition, the higher the level of therapeutic alliance at week 2 of the intervention the greater the reduction in psychological distress and increase in mental well-being over the program. Finally, they found that if the therapeutic alliance was weak at week 2 then there was less improvement in psychological distress in the group version of MBCT than the online version.

 

These results are in line with previous findings that mindfulness training produces improves mental well-being and decreases psychological distress in cancer patients, that online mindfulness training is effective, and that therapeutic alliance is important for the effectiveness of mindfulness training. These results suggest that the development of therapeutic alliance be emphasized in mindfulness training. It is interesting that therapeutic alliance can be just as effectively developed online as in person and that it is less responsive to early low therapeutic alliance. This may explain, in part, why online mindfulness training is very effective.

 

So, therapeutic alliance is important for mindfulness training to improve the psychological health of cancer patients.

 

mindfulness-based therapy is an effective way of treating anxiety and depression in cancer patients.” – Robert Zachariae

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Bisseling, E., Cillessen, L., Spinhoven, P., Schellekens, M., Compen, F., van der Lee, M., & Speckens, A. (2019). Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial. Journal of medical Internet research, 21(10), e14065. doi:10.2196/14065

 

Abstract

Background

Mindfulness-based cognitive therapy (MBCT) is an evidence-based group-based psychological treatment in oncology, resulting in reduction of depressive and anxiety symptoms. Internet-based MBCT (eMBCT) has been found to be an effective alternative for MBCT. The therapeutic alliance (the bond between therapist and patient,) is known to have a significant impact on psychological treatment outcomes, including MBCT. A primary concern in the practice of eMBCT is whether a good therapeutic alliance can develop. Although evidence for the beneficial effect of therapist assistance on treatment outcome in internet-based interventions (IBIs) is accumulating, it is still unclear whether the therapeutic alliance is related to outcome in IBIs.

Objective

This study aimed to (1) explore whether early therapeutic alliance predicts treatment dropout in MBCT or eMBCT, (2) compare the development of the therapeutic alliance during eMBCT and MBCT, and (3) examine whether early therapeutic alliance is a predictor of the reduction of psychological distress and the increase of mental well-being at posttreatment in both conditions.

Methods

This study was part of a multicenter randomized controlled trial (n=245) on the effectiveness of MBCT or eMBCT for distressed cancer patients. The therapeutic alliance was measured at the start of week 2 (ie, early therapeutic alliance), week 5, and week 9. Outcome measures were psychological distress, measured with the Hospital Anxiety and Depression Scale, and mental well-being, measured with the Mental Health Continuum-Short Form.

Results

The strength of early therapeutic alliance did not predict treatment dropout in MBCT or eMBCT (B=−.39; P=.21). Therapeutic alliance increased over time in both conditions (F2,90=16.46; Wilks λ=0.732; P<.001). This increase did not differ between eMBCT and MBCT (F1,91=0.114; P=.74). Therapeutic alliance at week 2 predicted a decrease in psychological distress (B=−.12; t 114=−2.656; P=.01) and an increase in mental well-being (B=.23; t 113=2.651; P=.01) at posttreatment. The relationship with reduction of psychological distress differed between treatments: a weaker early therapeutic alliance predicted higher psychological distress at posttreatment in MBCT but not in eMBCT (B=.22; t 113=2.261; P=.03).

Conclusions

A therapeutic alliance can develop in both eMBCT and MBCT. Findings revealed that the strength of early alliance did not predict treatment dropout. Furthermore, the level of therapeutic alliance predicted reduced psychological distress and increased mental well-being at posttreatment in both conditions. Interestingly, the strength of therapeutic alliance appeared to be more related to treatment outcome in group-based MBCT than in eMBCT.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827984/

 

Improve Well-Being in Nurses with Mindfulness

Improve Well-Being in Nurses with Mindfulness

 

By John M. de Castro, Ph.D.

 

“For nurses, many of them went into the field because of their ability to connect with people and make a difference in their lives. Mindfulness is a path to help us reconnect with what brings meaning to the profession. It brings humanity back to healthcare.” – Susan Bauer-Wu

 

Stress is epidemic in the western workplace with almost two thirds of workers reporting high levels of stress at work. In high stress occupations, like healthcare, burnout is all too prevalent. Burnout is the fatigue, cynicism, emotional exhaustion, sleep disruption, and professional inefficacy that comes with work-related stress. It is estimated that over 45% of healthcare workers experience burnout. It not only affects the healthcare providers personally, but also the patients, as it produces a loss of empathy and compassion. Burnout, in fact, it is a threat to the entire healthcare system. Currently, over a third of healthcare workers report that they are looking for a new job. Hence, burnout contributes to the shortage of doctors and nurses.

 

Preventing burnout has to be a priority. Unfortunately, it is beyond the ability of the individual to change the environment to reduce stress and prevent burnout. So, it is important that methods be found to reduce the individual’s responses to stress; to make the individual more resilient when high levels of stress occur. Contemplative practices have been shown to reduce the psychological and physiological responses to stress and improve well-being. Indeed, mindfulness has been shown to be helpful in treating and preventing burnoutincreasing resilience, and improving sleep. Hence, mindfulness may be a means to reduce burnout and improve well-being in nurses.

 

In today’s Research News article “Mindfulness to promote nurses’ well-being.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716566/), Penque recruited Registered Nurses (RNs). They participated in a Mindfulness-Based Stress Reduction (MBSR) program. The MBSR program consists of 8 weekly 1-hour group sessions involving meditation, yoga, body scan, and discussion. The participants were also encouraged to perform daily practice at home. They were measured before and after training and 3 months later for mindfulness, self-compassion, serenity, interpersonal reactivity, work satisfaction, and burnout.

 

She found that following the Mindfulness-Based Stress Reduction (MBSR) program there were significant increases in mindfulness, self-compassion including  self-kindness, common humanity, mindfulness, serenity, and interpersonal reactivity including perspective taking, and empathetic concern. There were also significant decreases in burnout, isolation, overidentification, self-judgment, and personal distress. She also found that the higher the levels of mindfulness, the higher the levels of self-compassion and serenity.

 

The results must be interpreted with caution as there wasn’t a control, comparison, group. So, potential confounds such as placebo effects, experimenter bias, Hawthorne effects, etc. were present. Other, better controlled studies, however, have demonstrated that mindfulness training increases self-compassion and reduces burnout. So, it is likely that these same benefits of mindfulness training occurred here irrespective of confounding conditions.

 

The Mindfulness-Based Stress Reduction (MBSR) program is a complex of meditation, yoga, and body scan practices. It is not possible to determine which components or combination of components were responsible for the benefits. Regardless, the results suggest that MBSR training is a safe and effective program to improve the well-being of nurses and reduce burnout. This can not only improve the psychological health of the nurses but also improve the retention of these valuable and important healthcare workers.

 

So, improve well-being in nurses with mindfulness.

 

Mindfulness can positively affect how nurses feel and cope with the pressures of their work, thereby resulting in better self-care and improved patient outcomes.” – Nursing Times

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Penque S. (2019). Mindfulness to promote nurses’ well-being. Nursing management, 50(5), 38–44. doi:10.1097/01.NUMA.0000557621.42684.c4

 

This article examines the effects of MBSR on job-relevant factors, including mindfulness, self-compassion, empathy, serenity, work satisfaction, incidental overtime, and job burnout. Nursing is a high-stress profession that may be taking a toll on our nurses. Mindfulness-based programs can help nurses develop skills to manage clinical stress and improve their health; increase overall attention, empathy, and presence with patients and families; and experience work satisfaction, serenity, decreased incidental overtime, and reduced job burnout.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716566/

 

High Frequency of Yoga Practice Produces Greater Benefits

High Frequency of Yoga Practice Produces Greater Benefits

 

By John M. de Castro, Ph.D.

 

Regular yoga practice creates mental clarity and calmness; increases body awareness; relieves chronic stress patterns; relaxes the mind; centers attention; and sharpens concentration. Body- and self-awareness are particularly beneficial, because they can help with early detection of physical problems and allow for early preventive action.” – Natalie Nevins

 

Yoga practice has been shown to have a myriad of benefits for psychological and physical health, social, and spiritual well-being. It is both an exercise and a mind-body practice that stresses both mental attention to present moment movements, breath control, and flexibility, range of motion, and balance. There has, however, not been much attention paid to the characteristics of practice that are important for producing maximum benefits.

 

In today’s Research News article “Effects of Yoga Asana Practice Approach on Types of Benefits Experienced.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746050/), Wiese and colleagues emailed a questionnaire to a large sample of yoga practitioners. They were asked for demographic information and to describe their yoga practice and physical, mental, emotional, spiritual, and relational benefits of yoga.

 

They found that the higher the frequency of practice the greater the physical, mental, emotional, spiritual, and relational benefits. Weaker relationships were found between consistency of practice, teaching yoga, and teacher experience and the benefits. In addition, there was a relationship between the frequency of practice without a teacher and self-confidence. Evening practice was found to be a negative predictor of benefits.

 

These findings suggest, as has been previously reported, that yoga practice produces myriad of benefits for psychological and physical health, social, and spiritual well-being. The characteristic of practice that was most highly related to these benefits was how many times per week yoga was practiced, particularly when the practice occurred 5 or more times per week; the more practice, the greater the benefits. Also associated with benefits were consistency of practice, teaching yoga, and teacher experience, while evening practice was associated with less benefit.

 

It should be noted that these results are correlations and caution must be exercised in assigning causation. But the findings are consistent with finding from controlled studies, suggesting that yoga practice produces great benefit.

 

So, practice frequently to obtain the greatest benefits from yoga practice.

 

Multiple studies have confirmed the many mental and physical benefits of yoga. Incorporating it into your routine can help enhance your health, increase strength and flexibility and reduce symptoms of stress, depression and anxiety. Finding the time to practice yoga just a few times per week may be enough to make a noticeable difference when it comes to your health.” – Rachel Link

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Wiese, C., Keil, D., Rasmussen, A. S., & Olesen, R. (2019). Effects of Yoga Asana Practice Approach on Types of Benefits Experienced. International journal of yoga, 12(3), 218–225. doi:10.4103/ijoy.IJOY_81_18

 

Abstract

Context:

Modern science and the classic text on hatha yoga, Hatha Yoga Pradipika, report physical, mental, emotional, spiritual, and relational benefits of yoga practice. While all have specific suggestions for how to practice, little research has been done to ascertain whether specific practice approaches impact the benefits experienced by practitioners.

Aims:

Our aim was to relate the experience level of the practitioner, the context of practice approaches (time of day, duration of practice, frequency of practice, etc.), and experience level of the teacher, to the likelihood of reporting particular benefits of yoga.

Methods:

We conducted a cross-sectional descriptive survey of yoga practitioners across levels and styles of practice. Data were compiled from a large voluntary convenience sample (n = 2620) regarding respondents’ methods of practice, yoga experience levels, and benefits experienced. Multiple logistic regression was used to identify approaches to yoga practice that positively predicted particular benefits.

Results:

Frequency of practice, either with or without a teacher, was a positive predictor of reporting nearly all benefits of yoga, with an increased likelihood of experiencing most benefits when the practitioner did yoga five or more days per week. Other aspects of practice approach, experience level of the practitioner, and the experience level of the teacher, had less effect on the benefits reported.

Conclusions:

Practice frequency of at least 5 days per week will provide practitioners with the greatest amount of benefit across all categories of benefits. Other practice approaches can vary more widely without having a marked impact on most benefits experienced.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746050/

 

Mindfulness Training is Effective with Widely Diverse Populations

Mindfulness Training is Effective with Widely Diverse Populations

 

By John M. de Castro, Ph.D.

 

“In the last two decades, references to mindfulness-based treatments have proliferated. Its benefits are touted for many medical conditions and seem to be universally accepted as a technique to improve mental health across diverse populations.” – Sara Davin

 

Disadvantaged populations have a disproportionate share of mental health issues. Indeed, the lower the socioeconomic status of an individual the greater the likelihood of a mental disorder. It is estimated that major mental illnesses are almost 3 times more likely in the disadvantaged, including almost double the incidence of depression, triple the incidence of anxiety disorders, alcohol abuse, and eating disorders. These higher incidences of mental health issues occur, in part, due to mental health problems leading to unemployment and poverty, but also to the stresses of life in poverty.

 

Most psychotherapies were developed to treat disorders in affluent western populations and are not affordable or sensitive to the unique situations and education levels of the diverse populations. Hence, there is a great need for alternative treatments for diverse populations. One increasingly popular alternative is mindfulness practices. These include meditationtai chi, qigongyoga, guided imagery, prayer, etc. The research on the effectiveness of mindfulness practices with diverse populations is accumulating, so it makes sense to stop and summarize what has been learned.

 

In today’s Research News article “Addressing Diversity In Mindfulness Research On Health: A Narrative Review Using The Addressing Framework.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746558/),Chin and colleagues review and summarize the published research studies on the effectiveness of mindfulness practice for various populations.

 

They report that the published studies found that mindfulness practice was beneficial regardless of age, being effective in children, adolescents, adults, and the elderly, regardless of ethnicity, including black, Hispanic, native American, and Asian populations, and regardless of sexual orientation, including lesbian, gay, bisexual, and transgender participants. Mindfulness training was also found to improve the well-being of patients with acquired disabilities including Alzheimer’s disease, diabetic peripheral neuropathy, traumatic brain injury, and multiple sclerosis. Mindfulness appears to be effective regardless of socioeconomic status, being beneficial in both affluent and poor participants and regardless of nationality, being beneficial for European Americans, Taiwanese, South Africans, British and Swedes. Finally, there’s only a small number of studies that compare the effectiveness of mindfulness practice for males versus females. In general, mindfulness practice appears to be beneficial for both genders, but possibly more beneficial for women than men.

 

These findings are quite striking and suggest that mindfulness training is beneficial for a wide variety of people with a wide variety of conditions. It is no wonder that mindfulness practice appears to be spreading rapidly, with meditation practice increasing from 4% to 14% of the US population over the last 5 years.

 

Hus, mindfulness training is effective with widely diverse populations.

 

“The application of mindfulness to diversity and inclusion is about opening and appreciating rather than rejecting difference.” – Joshua Ehrlich

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Chin, G., Anyanso, V., & Greeson, J. (2019). Addressing Diversity In Mindfulness Research On Health: A Narrative Review Using The Addressing Framework. Cooper Rowan medical journal, 1(1), 2.

 

INTRODUCTION

Over the past 5 years, the number of Americans practicing meditation has more than tripled, rising from 4% of adults in 2010 to 14% in 2017.1 This rise is likely related to the increasing focus on preventive and integrative approaches to healthcare in the United States, such as meditation, which is often used to reduce stress, anxiety, depression, and pain in conjunction with improving health and well-being.2 While many different meditative practices exist, mindfulness meditation emphasizes nonjudgmental awareness of the present moment. Although substantial research supports mindfulness-related improvements in patient-reported mental and physical health,3 the replication crisis in social science and medicine, alongside numerous methodological concerns about extant mindfulness studies,4 invites questions regarding the generalizability of research on the reported health-promoting effects of mindfulness meditation and mindfulness as an innate, dispositional quality (trait mindfulness). Moreover, as much of mindfulness research over-samples middle-to-upper class, Caucasian, women,5 the extent to which results generalize to a broader, more diverse population is unclear. One possible reason for this overrepresentation could be that this population has the time and/or finances to participate in mindfulness-based interventions (MBIs) from which researchers draw samples.

In 2001, Dr. Pamela Hays published Addressing Cultural Complexities in Practice,6 introducing the ADDRESSING framework as a guide to help clinicians better identify and understand the relevant cultural identities of their clients. According to Dr. Hays, the facets of identity include: Age, Developmental and acquired Disabilities, Religion, Ethnicity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender. This framework allows room for intersectionality between identity facets and does not inherently exclude non-minority individuals. As such, the ADDRESSING framework, with its attention to multiple aspects of identity, provides an effective structure for organizing research published on different populations and identifying 1) which populations are represented and underrepresented in various categories and 2) what is known about underrepresented groups in research. The main purpose of this review, therefore, was to use the ADDRESSING framework to highlight mindfulness research conducted on historically underrepresented groups as both a method to summarize what has been done and to point out gaps for future research.

Overall, mindfulness can reduce stress and improve mental health in diverse populations. Given the unique stressors and mental health disparities individuals in diverse groups experience, mindfulness-related changes in mental health likely support improvements in health-related behavior, QoL and well-being.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746558/

 

Improve Mindfulness Training with Natural Settings

Improve Mindfulness Training with Natural Settings

 

By John M. de Castro, Ph.D.

 

Our deepest origins lie in the natural world and time in the great outdoors can be calming, invigorating, beautiful… and lots of fun! Mindfulness is paying attention without judgement to the present moment and it’s the perfect way to enhance our connection with nature.”- Claire Thompson

 

Modern living is stressful, perhaps, in part because it has divorced us from the natural world that our species was immersed in throughout its evolutionary history. Modern environments may be damaging to our health and well-being simply because the species did not evolve to cope with them. This suggests that returning to nature, at least occasionally, may be beneficial. Indeed, researchers are beginning to study nature walks or what the Japanese call “Forest Bathing” and their effects on our mental and physical health.

 

Mindfulness practices have been found routinely to reduce the psychological and physiological responses to stress and improve mood. People have long reported that walking in nature elevates their mood. It appears intuitively obvious that if mindfulness training occurred in a beautiful natural place, it would greatly improve the effectiveness of mindfulness practice. Pictures in the media of meditation almost always show a practitioner meditating in a beautiful natural setting. But there is little systematic research regarding the effects of mindfulness training in nature. It’s possible that the combination might magnify the individual benefits of each.

 

In today’s Research News article “A Systematic Review and Meta-Analysis of Nature-Based Mindfulness: Effects of Moving Mindfulness Training into an Outdoor Natural Setting.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6747393/), Diernis and colleagues review and summarize the published research studies of the effects of combining mindfulness training with natural environments. They found 26 published studies.

 

They report that the published research studies found that mindfulness practice in nature produced greater improvements in psychological, social, and physical well-being with moderate to small effect sizes. These effects were present regardless of whether the study employed a no-treatment or active control condition. In addition, natural environments that were wild and/or forested tended to produce greater effects than natural environments that were garden or park environments.

 

The meta-analysis suggests that mindfulness training in the natural environment, especially in wild environments, produces greater benefits than similar training in non-natural settings. It is not clear why this would be true. Perhaps, removing the individual from the environments that their accustomed to, potentiates mindfulness training. Or perhaps, returning the individual to the type of environments that reflect their evolutionary history, reduces stress and produces greater relaxation and improved attention. Regardless, it’s clear that practicing mindfulness in nature is very beneficial.

 

So, improve mindfulness training with natural settings.

 

During my first mindfulness-in-nature retreat, when my hand touched the sun-warmed ground, I felt a connection to the Earth I didn’t know was possible. It was as if the energy of the Earth connected with my own. There was no separation. It was grounding, warm, and it felt like home.” – Sara Overton

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Djernis, D., Lerstrup, I., Poulsen, D., Stigsdotter, U., Dahlgaard, J., & O’Toole, M. (2019). A Systematic Review and Meta-Analysis of Nature-Based Mindfulness: Effects of Moving Mindfulness Training into an Outdoor Natural Setting. International journal of environmental research and public health, 16(17), 3202. doi:10.3390/ijerph16173202

 

Abstract

Research has proven that both mindfulness training and exposure to nature have positive health effects. The purpose of this study was to systematically review quantitative studies of mindfulness interventions conducted in nature (nature-based mindfulness), and to analyze the effects through meta-analyses. Electronic searches revealed a total of 25 studies to be included, examining 2990 participants. Three analyses were conducted: Nature-based mindfulness interventions evaluated as open trials (k = 13), nature-based mindfulness compared with groups in non-active control conditions (k = 5), and nature-based mindfulness compared with similar interventions but without contact with nature (k = 7). The overall combined psychological, physiological, and interpersonal effects from pre- to post-intervention were statistically significant and of medium size (g = 0.54, p < 0.001). Moderation analyses showed that natural environments characterized as forests/wild nature obtained larger numerical effects than environments characterized as gardens/parks, as did informal mindfulness compared with formal mindfulness. The small number of studies included, as well as the heterogeneity and generally low quality of the studies, must be taken into consideration when the results are interpreted

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6747393/

 

Improve Psychological Functioning with Mindfulness

Improve Psychological Functioning with Mindfulness

 

By John M. de Castro, Ph.D.

 

” the positive potential benefits of mindfulness practice are more attentional control, more effective emotional regulation, enhanced social relationships, reduced risk for physical ailments, enhanced immune system functioning, and better sleep quality.” – Jason Linder

 

Over the last several decades, research and anecdotal experiences have accumulated an impressive evidential case that the development of mindfulness has positive benefits for the individual’s mental, physical, and spiritual life. Mindfulness appears to be beneficial both for healthy people and for people suffering from a myriad of mental and physical illnesses. It appears to be beneficial across ages, from children to the elderly. And it appears to be beneficial across genders, personalities, race, and ethnicity. The breadth and depth of benefits is unprecedented. There is no other treatment or practice that has been shown to come anyway near the range of mindfulness’ positive benefits.

 

The clustering of these benefits may supply a clue as to how mindfulness training is working to improve mental health. This can be investigated by looking at the interrelationships between the effects of mindfulness training. In today’s Research News article “Does mindfulness change the mind? A novel psychonectome perspective based on Network Analysis.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6638953/), Roca and colleagues apply network analysis to investigate the interrelationships between a large number of effects of Mindfulness-Based Stress Reduction (MBSR) training.

 

They recruited healthy adult participants in a Mindfulness-Based Stress Reduction (MBSR) program. The MBSR program consisted of 32 hours of training separated into 8 weekly group sessions involving meditation, yoga, body scan, and discussion. The patients were also encouraged to perform daily practice. They were measured before and after MBSR training for meditation experience, and psychological and physical health problems, and 5 categories of mindfulness effects; 1) Mindfulness, including five facets, decentering, non-attachment, and bodily awareness, 2) Compassion, including compassion towards oneself and others and empathy, 3) Psychological well-being, including satisfaction with life, optimism, and overall well-being, 4) Psychological distress, including anxiety, stress, and depression, and 5) Emotional and cognitive control, including emotional regulation, rumination, thought suppression and attentional control.

 

They found that after MBSR training there were significant improvements in effectively all of the five categories. This is not new as much research has demonstrated that mindfulness training produces improvements in mindfulness, compassion, psychological well-being, psychological distress, and emotional and cognitive control.

 

These data were then subjected to network analysis. Prior to MBSR training the network analysis revealed clustering in three paths “mindfulness and self-compassion; clinical symptoms and rumination; and most of FFMQ mindfulness components with attentional control measure.” After MBSR training, however, there was a network reorganization such that the three paths disappeared and were replaced by two paths, psychopathological and adaptive.

 

Centrality measures in the network analysis indicated that both prior to and after MBSR training the most central, fundamental, and interrelated components were all facets of mindfulness and all well-being measures. In addition, Community Analysis revealed that mindfulness, compassion, and emotional regulation were the most highly associated components.

 

The results are complex but suggest that Mindfulness-Based Stress Reduction (MBSR) training reorganizes the associations of psychological variables, simplifying them into two categories representing distress and adaptation. The training may help the individual see the interrelationships of the problems they have and the solutions employed. The results further suggest, not surprisingly, that mindfulness, compassion, and emotion regulation are central to the benefits of mindfulness training. Many other benefits flow from these.

 

So, improve psychological functioning with mindfulness.

 

“Mindfulness-Based Stress Reduction . . . Participants experienced significant decreases in perceived stress, depression, anxiety, emotional dysregulation, and post-traumatic stress symptoms.” – Carolyn McManus

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Roca, P., Diez, G. G., Castellanos, N., & Vazquez, C. (2019). Does mindfulness change the mind? A novel psychonectome perspective based on Network Analysis. PloS one, 14(7), e0219793. doi:10.1371/journal.pone.0219793

 

Abstract

If the brain is a complex network of functionally specialized areas, it might be expected that mental representations could also behave in a similar way. We propose the concept of ‘psychonectome’ to formalize the idea of psychological constructs forming a dynamic network of mutually dependent elements. As a proof-of-concept of the psychonectome, networks analysis (NA) was used to explore structural changes in the network of constructs resulting from a psychological intervention. NA was applied to explore the effects of an 8-week Mindfulness-Based Stress Reduction (MBSR) program in healthy participants (N = 182). Psychological functioning was measured by questionnaires assessing five key domains related to MBSR: mindfulness, compassion, psychological well-being, psychological distress and emotional-cognitive control. A total of 25 variables, covering the five constructs, were considered as nodes in the NA. Participants significantly improved in most of the psychological questionnaires. More interesting from a network perspective, there were also significant changes in the topological relationships among the elements. Expected influence and strength centrality indexes revealed that mindfulness and well-being measures were the most central nodes in the networks. The nodes with highest topological change after the MBSR were attentional control, compassion measures, depression and thought suppression. Also, cognitive appraisal, an adaptive emotion regulation strategy, was associated to rumination before the MBSR program but became related to mindfulness and well-being measures after the program. Community analysis revealed a strong topological association between mindfulness, compassion, and emotional regulation, which supports the key role of compassion in mindfulness training. These results highlight the importance of exploring psychological changes from a network perspective and support the conceptual advantage of considering the interconnectedness of psychological constructs in terms of a ‘psychonectome’ as it may reveal ways of functioning that cannot be analyzed through conventional analytic methods.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6638953/

 

Mindfulness is Associated with Better Mental Health in Firefighters

Mindfulness is Associated with Better Mental Health in Firefighters

 

By John M. de Castro, Ph.D.

 

“mindfulness practices work at both a preventative and remedial level by assisting them to maintain higher levels of resilience to deal with their emergency responder roles and helping to reduce and cease distressing reactions after difficult personal and traumatic incidents.” – Mark Molony

 

Experiencing trauma is quite common. It has been estimated that 60% of men and 50% of women will experience a significant traumatic event during their lifetime with 7%-8% of the population developing Post-Traumatic Stress Disorder (PTSD). First responders such as firefighters and police experience traumatic events as part of their jobs and many develop symptoms of PTSD. This is responsible for the fact that wore firefighters and police officers die by suicide than all line-of-duty deaths combined. 103 firefighters and 140 police officers died by suicide in 2017, compared to 93 firefighter and 129 officer line-of-duty deaths.

 

Obviously, stress and trauma effects are troubling problems for firefighters that need to be addressed. There are a number of therapies that have been developed to treat PTSD. One of which, mindfulness training has been found to be particularly effective.  Indeed, mindfulness has been shown to has been shown to reduce the physiological and psychological responses to stress, to reduce suicidality and to reduce the impact of trauma on the individual. So, a firefighter’s level of mindfulness may be associated with better mental health.

 

In today’s Research News article “Mental health and mindfulness amongst Australian fire fighters.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570940/), Counson and colleagues recruited healthy firefighters who had experienced trauma in the last 6 months. The firefighters completed measures of mindfulness, anxiety, depression, and psychological well-being.

 

They found that the higher the firefighters’ levels of mindfulness, the lower the levels of anxiety and depression and the higher the levels of psychological well-being. Hence, mindfulness was found to be associated with better mental health in these firefighters who are exposed to trauma. This study is correlational and no conclusions regarding causation can be reached. But previous research has demonstrated that mindfulness has causal effects on anxiety, depression, and psychological well-being. So, it is likely that the associations seen here were due to causal connections.

 

These results suggest that mindful firefighters are resistant to the effects of trauma. It has been shown the mindfulness is effective in treating Post-Traumatic Stress Disorder (PTSD). The present results then combined with these previous findings suggest that mindfulness may help to protect firefighters from trauma making it less likely that they’ll develop PTSD.

 

So, mindfulness is associated with better mental health in firefighters.

 

targeted mindfulness training program increases some aspects of firefighter resilience (distress tolerance, positive adjustment, and perseverance). . . . The more lessons firefighters completed, the greater their improvements in both mindfulness and resilience.” – AMRA

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are available at the Contemplative Studies Blog http://contemplative-studies.org/wp/

They are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Counson, I., Hosemans, D., Lal, T. J., Mott, B., Harvey, S. B., & Joyce, S. (2019). Mental health and mindfulness amongst Australian fire fighters. BMC psychology, 7(1), 34. doi:10.1186/s40359-019-0311-2

 

Abstract

Background

While extensive research has highlighted the positive mental health outcomes associated with mindfulness, little work has examined how mindfulness may protect the mental health of first responders exposed to trauma. This is important as there is increasing evidence that mindfulness skills, if protective, can be taught to groups of at-risk workers. The purpose of the current research was to examine the potential role mindfulness may have in supporting the mental health of Australian fire fighters.

Methods

The sample consisted of 114 professional fire fighters who completed demographic and job-related questions followed by measures of mindfulness (FMI-14), well-being (WHO-5), depression (HADS-D) and anxiety (HADS-A). Hierarchical multiple linear regressions were performed to determine whether levels of mindfulness were associated with anxiety, depression and wellbeing after accounting for age and number of years of fire service.

Results

High levels of mindfulness were associated with decreased depression (p ≤ .001) and anxiety (p ≤ .001) as well as increased psychological well-being (p ≤ .001). Measures of mindfulness were able to explain a substantial amount of the variability in well-being (26.8%), anxiety (23.6%) and depression (22.4%), regardless of age and years of fire service.

Conclusions

The present study provides evidence for robust associations between dispositional mindfulness and mental health markers of depression, anxiety and well-being in Australian fire fighters recently exposed to trauma. Mindfulness is a psychological characteristic that may be able to be modified, although further research is required to substantiate these findings and to formally test mindfulness interventions. Such studies would allow greater insight into the underlying mechanisms through which mindfulness may exert its beneficial effects.

Electronic supplementary material

The online version of this article (10.1186/s40359-019-0311-2) contains supplementary material, which is available to authorized users.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570940/