key: cord-1030604-nmb697s3 authors: Farris, Suzan R; Grazzi, Licia; Holley, Miya; Dorsett, Anna; Xing, Kelly; Pierce, Charles R; Estave, Paige M; O’Connell, Nathaniel; Wells, Rebecca Erwin title: Online Mindfulness May Target Psychological Distress and Mental Health during COVID-19 date: 2021-03-17 journal: Glob Adv Health Med DOI: 10.1177/21649561211002461 sha: 94e9197cabdb3cd9283dcba80355dd135d66b6b1 doc_id: 1030604 cord_uid: nmb697s3 BACKGROUND: The COVID-19 pandemic has dramatically affected mental health, creating an urgent need for convenient and safe interventions to improve well-being. Online mindfulness interventions show promise for improving depression, anxiety, and general well-being. OBJECTIVE: To assess: 1) the impact of online mindfulness on psychological distress, 2) altruistic efforts, and 3) the quantity, quality, and availability of online mindfulness resources during the COVID-19 pandemic. METHODS: 233 participants (203 U.S.; 20 international; 10 unknown) participated in this prospective, single-arm, non-randomized clinical trial of a single online mindfulness meditation session with pre- and post-surveys. MAIN OUTCOME MEASURES: (a) Mindfulness session helpfulness, online platform effectiveness, and immediate pre- to post-session changes in momentary stress, anxiety, and COVID-19 concern; (b) qualitative themes representing how people are helping others during the pandemic; (c) absolute changes in quantity of mindfulness-oriented web content and free online mindfulness resource availability from May to August 2020. RESULTS: Most participants felt the online mindfulness session was helpful and the electronic platform effective for practicing mindfulness (89%, 95% CI: [82 to 93%]), with decreased momentary anxiety (76%; 95% CI: [69 to 83%]), stress (80%; [72 to 86%]), and COVID-19 concern (55%; [46 to 63%]), (p < 0.001 for each measure). Participants reported helping others in a variety of ways during the pandemic, including following public health guidelines, conducting acts of service and connection, and helping oneself in hopes of helping others. “Mindfulness + COVID” search results increased by 52% from May to August 2020. Most (73%) Academic Consortium for Integrative Medicine and Health member websites offer free online mindfulness resources. CONCLUSIONS: Virtual mindfulness is an increasingly accessible intervention available world-wide that may reduce psychological distress during this isolating public health crisis. Kindness and altruism are being demonstrated during the pandemic. The consolidated online mindfulness resources provided may help guide clinicians and patients. The COVID-19 pandemic and subsequent social isolation has exerted alarmingly negative effects on mental health with stress, anxiety, and depression 1 in the general public 2,3 and in healthcare workers. [4] [5] [6] This negative impact has exacerbated pre-existing depressive symptoms 7 and stress-susceptible medical conditions (e.g., migraine). 8, 9 Daily surveys conducted March 10th to March 16th 2020 showed each additional day was significantly associated with an 11% increase in psychological distress. 7 As of March 23, 2020, 53 countries had active statewide or national stay-at-home orders to reduce the virus' spread, 10 necessitating remotely accessible interventions to address the pandemic's psychological harms. Mindfulness targets stress and anxiety 11 by cultivating moment-to-moment awareness with open, non-reactive, non-judgmental attention. 12 Online mindfulness interventions have shown promise for improving depression, anxiety, and general well-being, with guided interventions exerting stronger effects than self-directed practice. 13 Online mindfulness programs may also reduce burnout in healthcare workers, 14 are accessible from home, and may provide unique benefits in a socially-distanced world transformed by Times of crisis can promote prosocial behavior and a sense of community; 15 helping others can benefit both the helped and the helper by providing meaning, improving mental health, and mitigating the negative effects of stress. 16, 17 This study was inspired by "Mindfulness for Milan," a program in which an Italian physician (LG) led free daily mindfulness sessions as part of a larger public health response designed to educate the public and manage stress and anxiety during the lockdown period. 15 This prospective, single-arm, non-randomized clinical trial aimed to 1) examine the helpfulness and platform effectiveness of a single virtual mindfulness session for reducing momentary stress, anxiety, and concern about COVID-19 in patients with migraine, healthcare workers, and the public; 2) identify modalities of service to others during COVID-19; and 3) evaluate the quantity, quality, and availability of online mindfulness resources across time during the pandemic. Study information and materials were distributed via web link from March 23rd to August 4th 2020 to recruit patients with migraine, healthcare providers, and the general public. There were no exclusions for participation, and all interested were eligible. Recruitment methods varied based on target populations. Migraine patients were recruited a) regionally through EMR batch messaging and direct notification at patient visits; b) nationally through notification of headache providers; c) internationally through Migraine World Summit. Healthcare providers and their patients were recruited nationwide through physician social media groups, listservs, and institutional emails. The principal investigator also contacted headache providers directly (see Acknowledgements). Recruitment of the general public, including healthcare providers, occurred through the institution's employee wellness program, local church communications, Clinicaltrials.gov, social media (e.g. Facebook, Twitter), ResearchMatch.org, 18 and Clara Health. Participants used a single web link to access the consent form and watch a 15-minute guided video mindfulness session embedded between pre-and post-REDCap surveys (surveys available in Online Supplemental Material). A physician and mindfulness instructor, wearing a white coat, introduced herself and described the session, its intentions, and its inspirations as an opportunity for her to be of service during the pandemic, inspired by a similarly designed Italian virtual mindfulness program. She provided an overview of mindfulness and led participants in a guided mindfulness session by providing calm guidance on bringing attention to the present moment, to the breath, and on "being." Participants were encouraged to gently release thoughts, feelings, and sensations while repeatedly returning attention to the breath. Bells signaled the guided mindfulness session's initiation and conclusion. The study was approved by the institution's Institutional Review Board and registered at clinicaltrials.gov NCT04319445. All participants provided informed consent prior to study participation. Primary outcomes included Likert scale ratings of session helpfulness and platform effectiveness. Secondary outcomes included: changes in momentary anxiety level, stress level, and COVID-19 concern; value of and satisfaction with the session; and percent interested in future sessions and willingness for family/friend recommendations. Participants were queried on how they were helping others during the pandemic (free text responses) by responding to the statement, "We are hopeful this session was helpful for you. We are also hopeful we may have inspired you to think of ways that YOU may be helpful during this pandemic. Have you thought of any ideas of what YOU can do to help OR are you actively helping others during this pandemic? If so, please describe." To assess online mindfulness resource availability, Google search engine was used to search "mindfulness þ COVID" on May 19, 2020 and August 23, 2020. Study team members further evaluated Academic Consortium for Integrative Medicine & Health (ACIMH) member webpages by searching "MBSR" (Mindfulness-Based Stress Reduction, a standardized curriculum of 8 weekly classes 12 ) and "mindfulness" within each page. To develop a consolidated list of excellent online mindfulness resources that address COVID-19, the top options from both the Google and ACIMH searches were selected, and then finalized to a list of 10 excellent resources based on source reputation, content quality, quantity, and format. All statistical analyses were performed using R Statistical Software. 19 Response variables were measured on a 5-item Likert scale (e.g., none at all, a little, somewhat, quite a bit, very much). We analyzed each Likert Scale response using a cumulative logit mixed model with time (pre vs. post) as a main effect and random intercepts by participant. The proportional odds assumption was checked via the Brant Test. 20 Baseline characteristics and additional responses were analyzed using descriptive statistics. In an exploratory analysis, potential differential changes in anxiety, stress, and concern in healthcare providers and patients with migraine were assessed through inclusion of an interaction effect with time in separate models. Only data from participants who completed surveys immediately before and after the session were included in quantitative analyses (n ¼ 144, given assessments included momentary stress/anxiety/concern). Reasons for delayed post-survey completion were captured in 24 participants (with resulting quantitative data exclusion) and included: continued meditation (n ¼ 5), technical difficulties (n ¼ 13), unawareness of post-survey (n ¼ 3), distractions (n ¼ 3). Data are reported with a 95% confidence interval (CI) and a significance level of p < 0.05. A constructivist grounded theory approach was used to assess all post-survey qualitative data (n ¼ 168, e.g., 144 plus 24) regarding how individuals have been offering acts of kindness during the COVID-19 pandemic. All survey responses were reviewed to create a master codebook, which was reviewed individually by two coders (REW and PME) until no new codes emerged. Related codes were then combined, and themes were developed and organized into categories. An iterative process ensued until all coders agreed on emerged themes and categories. To ensure authenticity and rigor, an audit trail was kept for result validity. surveys immediately after the session. Most participated within the first week (53%) or first month (83%) of recruitment. 94% watched the video; 6% only listened. Most participants were female (85%), employed fulltime (45%) or retired (21%), with a bachelor's or graduate degree (70%), and an average age of 48.6 (SD ¼ 15.6). Participants were 84% white, 7% Asian, 5% Black, 2% American Indian or Alaska Native, and 2% other/unknown. Nearly half (45%) reported a history of migraine, with 5.17 (SD ¼ 8.7) average headaches/month; one-quarter (24%) were healthcare providers. Most (63%) had never practiced mindfulness. Most participants felt the session was helpful (89%, 95% CI: [82 to 93%]) and perceived the electronic platform effective for practicing mindfulness (89% [82 to 93%]). After practicing mindfulness, participants had significantly decreased odds (e.g., reduction of at least 1 level in the 5 point Likert scale) of momentary anxiety, momentary stress, and momentary COVID-19 concern (p < 0.001 for each measure were interested in learning more about mindfulness (yes 65%, maybe 24%), would participate again (yes 69%, maybe 22%), and would recommend to friends/ family (yes 74%, maybe 21%). Participants reported wanting additional sessions weekly (48%), daily (36%), or monthly (17%). Patients with migraine and healthcare providers had similar improvements in stress, anxiety, and concern (no statistically significant difference identified between groups). 39% of participants who completed the post-surveys immediately (n ¼ 144) or after a delay (n ¼ 24) provided free-text responses of being helpful during the pandemic. Qualitative analysis revealed three meta-themes (Table 1) Figure 2 . Momentary anxiety, stress, and concern over COVID-19 significantly decreased after a single mindfulness session (p < 0.001 for each measure), reflecting answers to these questions asked before and after the mindfulness session, respectively: At this moment, how anxious do you feel? At this moment, how much stress do you feel? At this moment, how concerned are you about the coronavirus pandemic? No participants had "A lot" of stress post-mindfulness. Helping Those in Need a Friends/Family "I've been helping family and friends who can't or shouldn't be getting out get groceries and supplies that they need" "Well for me it's getting my garden ready for planting my seedling to produce organic food to share with family and friends. . ." a Neighbors "Yes, have offered to purchase groceries for neighbors" "I am creating family seed packs for my neighbors and encouraging them to grow non-GMO, heirloom vegetables in their yards" a Elderly ". . .I am helping walk my elderly neighbor's dog with my roommates" ". . .Making sure elderly neighbors have everything they need" "[We have] groups to go food shopping for the elderly" a Vulnerable and Disabled "I have been helping people who can't get out. . ." "Taking care of my disabled son during this time" "[I] help donate to my local shelter" a Patients "I am caring for patients in the ER as a physician" a Student and Teachers ". . .I am putting great time and energy into my lesson plans for my students, making them thorough enough for parents to execute and still enjoyable and engaging for students" "Using our extra money from reduction in daycare tuition to pay the teachers directly. . ." ". . . I video meet with teachers in rural areas of Nicaragua and Peru to help with brainstorming ideas and to listen to their concerns" Maintaining Connections with Others b Friends/Family "Listen to friends and family process their emotions. . ." "Providing a knowledgeable and understanding listening ear for those who are anxious. Simply being available and remaining calm" ". . .Checking in on friends and family via video calls" b Those Living Alone ". . . What I am doing is contacting old friends, family, anyone I know is living alone in the hopes of connecting with them" "Checking in on my single friends" b Spiritual Community "I have stayed in touch with members of a Sunday school class I teach and have continued to do that electronically. My wife has stayed in close communication with neighbors" "I send encouraging notes to church members and family" (continued) minimizing personal exposure risk; (2) self-renewing activities and self-compassionate attitudes; (3) staying positive and calm. Notably, there was a sense of commonality during this time of crisis among the responses, with many describing the importance of a positive attitude and self-compassion. Several participants recognized the public health service of staying home or social distancing to decrease exposure risk. Others felt the best way to help others was sharing COVID-19 facts via social media or directly with friends/family. Participants described direct acts of service and acknowledged the value of maintaining social connections virtually or via phone. Interestingly, this data revealed participants reaching out specifically to vulnerable populations (elderly, disabled, and those living alone). Many participants also referenced reconnecting with neighbors. Even those limiting personal exposure found ways to help others, such as through humor. ". . .I am staying in as I am in a high risk category, over 60 and have preexisting health conditions" "I am immune compromised but have walked and waved at neighbors" "I want to, but am immune compromised so walking only. I am hanging out stuffed animals in trees daily for the amusement of others walking by our home" Self-renewing Activities and Self-compassionate Attitudes "To take a few moments each day to learn not to worry so much about this pandemic. Going for short walk. To be outside even if it's just sitting in the yard at home enjoying sounds of nature" "Trying to be patient with myself knowing that I can only do so much" Staying Positive and Calm "Thinking positive thoughts" "Keeping positive" ". . .We generally try to convey a sense of calm and optimism that we will get through this" a Groups being helped by participants. b Groups being communicated with by participants. 8 Global Advances in Health and Medicine (Table 2 ). A consolidated list of excellent online mindfulness resources to directly help patients and providers during COVID-19 is provided (Table 3 ). Our study demonstrates that a single online mindfulness session is helpful and provides immediate decreases in momentary stress, anxiety, and COVID-related concern, with similar effects seen in migraine patients, healthcare workers, and the general public. The online platform provided breadth and flexibility for recruitment and access, and participants found it effective for practicing mindfulness. Most participants in our study were mindfulness-naı¨ve, demonstrating increased interest in mindfulness and the value of online access. Participants endorsed multiple, multimodal efforts to help others during the pandemic through adherence to public health recommendations, direct service to others, and self-care. Throughout the height of stay-at-home orders, online mindfulness resource availability dramatically increased. Both the Google and ACIMH member website searches demonstrated the broad variety and depth of online mindfulness offerings and resources across the United States. Many programs have converted previously inperson mindfulness and/or MBSR classes to online options. Mindfulness apps, web-based programs, and mindfulness instructors expanded offerings or eliminated fees to mitigate the pandemic's negative psychological effects. For example, Jon Kabat-Zinn (the founder of MBSR) live-streamed meditation sessions with dialogue and inquiry with international participation weekdays from March 30 th to June 26 th , 2020; these 65 videos are still available to the public on the Wisdom 2.0 YouTube channel. Online mindfulness interventions may improve psychological health at a time of uncertainty, chaos, and distress. These interventions offer momentary improvements in state function (e.g., reducing pandemic-induced elevations in state anxiety 21 ) while potentially creating new frameworks for processing stress, 13 enhancing resilience, 22 and increasing self-compassion and concern for others. 23 Mindfulness may increase happiness and wellbeing in healthcare workers by cultivating self- Online mindfulness offerings and links provided as available at time of searches (Fall 2020); some may change or additional resources become available. compassion 24 and reducing burnout, which can improve the quality and safety of healthcare delivery in a time of increased burden on healthcare systems. 14 The magnitude and effects of pandemic-induced stress may be different across groups or roles. For example, parents, teachers, and healthcare workers have been required to exert new levels of flexibility. A history of depressive symptoms may increase the risk for mental distress during the pandemic, 7 and those at greatest risk of COVID-related morbidity may be more isolated and/or fearful. 7 Those with stress-susceptible medical conditions may have disease exacerbations in response Many websites include summary lists with additional links to additional websites that also include excellent information; the ones presented were chosen based on source reputation, content quality, quantity, and format. b Online mindfulness offerings and links provided as available at time of searches (Fall 2020); some may change or additional resources become available. to COVID-related stress, seen with the increased frequency of migraine during the pandemic by some, 9 but not all. 25 Interventions that target psychological distress may thus provide differential responses based on need. Since this program was created as an act of service, participants were asked to share their ideas and acts of service. A sense of unity in the universal experiences of COVID-19 emerged. The pandemic seemed to create an enhanced sense of needing to help others, especially those in greatest need. Neighborly affection was represented, suggesting that stay-at-home orders may have provided an opportunity to reconnect with those in close home proximity who are often overlooked in the frenzied pace of typical life. Due to social distancing measures, people are actively and meaningfully finding ways to engage with those of importance. Participants described providing a "listening ear" and sending letters, modalities often forgotten in our technologically-savvy and text-friendly world. Several participants specifically commented on generating new ideas for serving others during the mindfulness session itself. The act of practicing mindfulness, therefore, may increase the innate desire to help through loving-kindness, which cultivates both self-compassion and concern for others' suffering. 23 While the pandemic has created great sadness, loss, and distress, our results demonstrate the potential positives emerging from such a devastating experience. Further research is needed to evaluate the pandemic's effects on post-traumatic growth (the positive psychological change experienced following a challenging life circumstance). 26, 27 The international inspiration for this study demonstrates 1) how one person's act of service can inspire others; 2) the value of communication during a crisis; 3) the beauty of international collegiality and friendship; and that 4) mindfulness is a cross-cultural approach with international interest and availability. Servant leadership is a powerful way to inspire others to serve. 28 The participants' acts of service described in this study may also serve as a source for future inspiration for others as well. Important strengths of this study include the timing of this study, initiated at the height of early pandemic response, and capturing the impact of a mindfulness session at a time of great anxiety and distress. The exclusively online format allowed for international recruitment, delivery, and participation, increasing access and availability. This study uniquely examined the effects of an online mindfulness intervention in the context of pandemic lockdown. Capturing participants' altruism highlights the positivity of humankind. The online mindfulness tables may provide unique tools to guide those who are interested in mindfulness but feel overwhelmed by the volume of available resources (Tables 2 and 3) . This study has several important limitations. Using a single, participant-specific REDCap link to embed the mindfulness session between pre-and post-surveys resulted in several challenges for immediate post-survey completion (e.g., technological difficulties, continued meditation practice, distractions), creating potential post-survey response bias. Surveys assessed state anxiety and stress and did not evaluate clinical depression and anxiety. Observed improvements may only reflect results for meditation-naı¨ve participants and/or those with interest in mindfulness meditation. The dramatic impact on psychological distress may be attributed to the timing of the study, as 83% participated within a month of study onset at the potential height of pandemic-induced stress. Further investigation is needed to understand the reasons behind lack of participant diversity: recruitment methods vs. lack of interest or access. While online programs improve accessibility, lack of internet or low technological proficiency may create disparities for some populations. Interestingly, 21% of participants were retired, suggesting that age did not preclude online accessibility, which may reflect forced technology use on all ages by the pandemic. Study side effects were not assessed, though harm is infrequent with guided mindfulness interventions. 29 The themes that emerged for ways of helping others may be specific to those practicing mindfulness (e.g., sharing mindfulness with others) and the recruitment strategies utilized (e.g., spiritual communities). Though participants reported helping behaviors during COVID-19, mindfulness' effects on the desire to help others were not assessed. While "COVID-19 concern" was assessed in an attempt to examine potentially damaging anxiety associated with COVID, a certain amount of concern may be important and needed to prompt appropriate and responsible pandemic responses, such as mask-wearing. Table 2 highlights mindfulness resources from the ACIMH member websites; additional non-ACIMH mindfulness programs, websites, and resources exist. Both Tables 2 and 3 were created to serve as resources for patients and providers but changes, updates, and/or additional resources may become available since the time of the original online searches (Fall 2020). This study included one brief mindfulness session. Future research should assess the longitudinal impact of regular online guided mindfulness practice. Future studies would be strengthened with longer study time and more than one session. As loneliness is an important component of pandemic-induced psychological harm, 30 studies that assess the impact of online mindfulness interventions on feelings of loneliness and isolation may help improve targeted approaches to pandemicrelated distress. Comparisons between guided vs. selfled mindfulness could help guide recommendations. In summary, our study suggests that online mindfulness interventions are feasible, increasingly available, and serve a novel and crucial function in the setting of social distancing to improve pandemic-related psychological effects. Participants world-wide are demonstrating altruistic behaviors with acts of compassion and kindness during the pandemic, finding meaningful ways to connect with others in ways rarely done in the pre-pandemic world. The opportunity to help others during the pandemic highlights the unique capacity of the human spirit to find positivity amidst devastatingly negative circumstances. 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We are thankful for all the providers who referred patients or promoted the study, both those unidentified and identified, including Drs. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: NCCIH K23AT008406 (PI-Wells). Rebecca Erwin Wells https://orcid.org/0000-0001-7609-497X Supplemental material for this article is available online.