Mindfulness‐based stress reduction for family carers of people with dementia

Zheng Liu; Yu‐Ying Sun; Bao‐liang Zhong

doi:10.1002/14651858.CD012791.pub2

Cochrane Database of Systematic Reviews

Mindfulness‐based stress reduction for family carers of people with dementia

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DOI:

https://doi.org/10.1002/14651858.CD012791.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

14 agosto 2018see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Demencia y trastornos cognitivos

Copyright:

Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Zheng Liu

Correspondencia a: Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China

[email protected]

[email protected]
Yu‐Ying Sun

Public Health, The Chinese University of Hong Kong, Hong Kong, China
Bao‐liang Zhong

Psychiatry, The Chinese University of Hong Kong, Hong Kong, China

Contributions of authors

ZL: designed the study and drafted the full review.

YYS and BLZ: took part in the study design, data collection, and analysis.

Sources of support

Internal sources

Department of Psychiatry, the Chinese University of Hong Kong, China.
School of Public Health, Peking University, China.

External sources

NIHR, UK.

This review was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Dementia and Cognitive Improvement group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service or the Department of Health

Declarations of interest

Zheng Liu: none known
Yu‐Ying Sun: none known
Bao‐liang Zhong: none known

Acknowledgements

We would like to thank the following people from the Department of Psychiatry, the Chinese University of Hong Kong: Prof Linda Chiu‐Wa Lam, Prof Sing Lee, and Prof Arthur Dun‐Ping Mak for their patient guidance and continuous support throughout the period of study design.

Version history

Published

Title

Stage

Authors

Version

2018 Aug 14

Mindfulness‐based stress reduction for family carers of people with dementia

Review

Zheng Liu, Yu‐Ying Sun, Bao‐liang Zhong

https://doi.org/10.1002/14651858.CD012791.pub2

2017 Sep 05

Mindfulness‐based stress reduction for family carers of people with dementia

Protocol

Zheng Liu, Yu‐Ying Sun, Bao‐liang Zhong

https://doi.org/10.1002/14651858.CD012791

Differences between protocol and review

Due to the paucity of information on adverse events, we described our study objectives as "to assess the effectiveness of MBSR in reducing the stress of family carers of people with dementia."
Due to the variability of control groups, we regrouped outcomes into two comparisons: MBSR versus active controls, and MBSR versus inactive controls.
As no included studies evaluated the effects of MBSR on institutionalisation, we did not report this outcome in the 'Summary of findings' tables.
We reported adverse events as one of main results in the review.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 MBSR versus active control at immediately postintervention, outcome: 1.1 Depressive symptoms.

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Figure 5

Forest plot of comparison: 1 MBSR versus active control at immediately postintervention, outcome: 1.4 Carer burden.

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Figure 6

Forest plot of comparison: 1 MBSR versus active control at immediately postintervention, outcome: 1.7 Dropout rates.

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Figure 7

Forest plot of comparison: 2 MBSR versus inactive control at immediately postintervention, outcome: 2.1 Depressive symptoms.

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Analysis 1.1

Comparison 1 MBSR versus active control immediately postintervention, Outcome 1 Depressive symptoms.

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Analysis 1.2

Comparison 1 MBSR versus active control immediately postintervention, Outcome 2 Clinically significant depressive symptoms.

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Analysis 1.3

Comparison 1 MBSR versus active control immediately postintervention, Outcome 3 Anxiety.

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Analysis 1.4

Comparison 1 MBSR versus active control immediately postintervention, Outcome 4 Carer burden.

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Analysis 1.5

Comparison 1 MBSR versus active control immediately postintervention, Outcome 5 Coping style.

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Analysis 1.6

Comparison 1 MBSR versus active control immediately postintervention, Outcome 6 Dropout rates.

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Analysis 2.1

Comparison 2 MBSR versus inactive control immediately postintervention, Outcome 1 Depressive symptoms.

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Analysis 2.2

Comparison 2 MBSR versus inactive control immediately postintervention, Outcome 2 Clinically significant depressive symptoms.

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Analysis 2.3

Comparison 2 MBSR versus inactive control immediately postintervention, Outcome 3 Anxiety.

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Analysis 2.4

Comparison 2 MBSR versus inactive control immediately postintervention, Outcome 4 Carer burden.

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Analysis 2.5

Comparison 2 MBSR versus inactive control immediately postintervention, Outcome 5 Coping style.

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Analysis 2.6

Comparison 2 MBSR versus inactive control immediately postintervention, Outcome 6 Dropout rates.

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Analysis 3.1

Comparison 3 MBSR versus active control within 3‐month follow‐up, Outcome 1 Depressive symptoms.

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Analysis 3.2

Comparison 3 MBSR versus active control within 3‐month follow‐up, Outcome 2 Carer burden.

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Analysis 4.1

Comparison 4 MBSR versus inactive control within 3‐month follow‐up, Outcome 1 Depressive symptoms.

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Analysis 4.2

Comparison 4 MBSR versus inactive control within 3‐month follow‐up, Outcome 2 Clinically significant depressive symptoms.

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Analysis 4.3

Comparison 4 MBSR versus inactive control within 3‐month follow‐up, Outcome 3 Anxiety.

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Analysis 5.1

Comparison 5 MBSR versus active control within 3‐ to 6‐month follow‐up, Outcome 1 Depressive symptoms.

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Analysis 5.2

Comparison 5 MBSR versus active control within 3‐ to 6‐month follow‐up, Outcome 2 Clinically significant depressive symptoms.

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Analysis 5.3

Comparison 5 MBSR versus active control within 3‐ to 6‐month follow‐up, Outcome 3 Anxiety.

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Analysis 5.4

Comparison 5 MBSR versus active control within 3‐ to 6‐month follow‐up, Outcome 4 Carer burden.

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Summary of findings for the main comparison. MBSR compared to active control for family carers of people with dementia

MBSR (mindfulness‐based stress reduction) compared to active control for family carers of people with dementia
Patient or population: family carers of people with dementia Setting: community Intervention: MBSR Comparison: active control
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with active control	Risk with MBSR
Depressive symptoms assessed with: CESD, POMS‐depression subscale Scale from 0 to 60 follow‐up: range 7 weeks to 8 weeks	‐	SMD 0.63 SD lower (0.98 lower to 0.28 lower)	‐	135 (3 RCTs)	⊕⊕⊝⊝ LOW ^{a b}	Moderate effect size;^c lower score represents lower depressive symptoms
Anxiety assessed with: STAI‐state anxiety subscale Scale from 20 to 80 follow‐up: 8 weeks	The mean anxiety was 47.4 score.	MD 7.5 score lower (13.11 lower to 1.89 lower)	‐	78 (1 RCT)	⊕⊕⊝⊝ LOW ^{a b}	Moderate effect size;^c lower score represents lower level of anxiety
Carer burden assessed with: MBCBS‐subjective stress burden, RMBPC‐reaction, ZBI Scale from 0 to 100 follow‐up: range 7 weeks to 8 weeks	‐	SMD 0.24 SD higher (0.11 lower to 0.58 higher)	‐	135 (3 RCTs)	⊕⊕⊝⊝ LOW ^{a b}	Small effect size;^c lower score represents lower level of carer burden
Dropout rates follow‐up: range 7 weeks to 8 weeks	Study population		RR 1.39 (0.32 to 5.99)	166 (4 RCTs)	⊕⊝⊝⊝ VERY LOW ^{a d}	Important effect size^e
	88 per 1000	122 per 1000 (28 to 524)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CESD: Center for Epidemiological Studies Depression Scale; CI: confidence interval; MBCBS: Montgomery Borgatta Caregiver Burden Scale; MD: mean difference; POMS: Profile of Mood States: RCT: randomised controlled trial; RMBPC: Revised Memory and Behavior Problems Checklist; RR: risk ratio; SD: standard deviation; SMD: standardised mean difference; STAI: State‐Trait Anxiety Inventory; ZBI: Zarit Burden Interview
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aWe downgraded the quality of evidence by one level due to serious concern about high risk of bias in blinding of participants and personnel. ^bAs suggested by Ryan 2016a, we downgraded the quality of evidence by one level due to serious concern about imprecision. ^cTo assess the magnitude of effect for continuous outcomes, we used the criteria suggested by Cohen 1988: 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. ^dAs suggested by Ryan 2016a, we downgraded the quality of evidence by two levels due to very serious concern about imprecision. ^eAs suggested by Ryan 2016b, we considered an RR < 0.75 or RR > 1.25 an important effect size for dichotomous outcomes.

Summary of findings for the main comparison. MBSR compared to active control for family carers of people with dementia

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Summary of findings 2. MBSR compared to inactive control for family carers of people with dementia

MBSR (mindfulness‐based stress reduction) compared to inactive control for family carers of people with dementia
Patient or population: family carers of people with dementia Setting: community Intervention: MBSR Comparison: inactive control
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with inactive control	Risk with MBSR
Depressive symptoms assessed with: CESD Scale from 0 to 60 follow‐up: range 7 weeks to 8 weeks	The mean depressive symptoms was 14.2 score.	MD 1.97 score lower (6.89 lower to 2.95 higher)	‐	50 (2 RCTs)	⊕⊕⊝⊝ LOW ^{a b}	Small effect size;^c lower score represents lower depressive symptoms
Anxiety assessed with: STAI‐state anxiety Scale from 20 to 80 follow‐up: 8 weeks	The mean anxiety was 47.8 score.	MD 7.27 score lower (14.92 lower to 0.38 higher)	‐	33 (1 RCT)	⊕⊕⊝⊝ LOW ^{a b}	Moderate effect size;^c lower score represents lower level of anxiety
Carer burden assessed with: RMBPC‐reaction Scale from 0 to 96 follow‐up: 7 weeks	The mean carer burden was 26.4 score.	MD 1.6 score lower (19.48 lower to 16.28 higher)	‐	17 (1 RCT)	⊕⊕⊝⊝ VERY LOW ^{b d}	Small effect size;^c lower score represents lower level of carer burden
Dropout rates follow‐up: 7 weeks	Study population		RR 2.00 (0.21 to 18.69)	20 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{b d}	Important effect size^e
	100 per 1000	200 per 1000 (21 to 1000)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CESD: Center for Epidemiological Studies Depression Scale; CI: confidence interval; MD: mean difference; RCT: randomised controlled trial; RMBPC: Revised Memory and Behavior Problems Checklist; RR: risk ratio; STAI: State‐Trait Anxiety Inventory
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aAs suggested by Ryan 2016a, we downgraded the quality of evidence by one level due to serious concern about imprecision. ^bWe downgraded the quality of evidence by one level due to serious concern about high risk of bias in blinding of participants and personnel. ^cTo assess the magnitude of effect for continuous outcomes, we used the criteria suggested by Cohen 1988: 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. ^dAs suggested by Ryan 2016a, we downgraded the quality of evidence by two levels due to very serious concern about imprecision. ^eAs suggested by Ryan 2016b, we considered an RR < 0.75 or RR > 1.25 an important effect size for dichotomous outcomes.

Summary of findings 2. MBSR compared to inactive control for family carers of people with dementia

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Comparison 1. MBSR versus active control immediately postintervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Depressive symptoms Show forest plot	3	135	Std. Mean Difference (IV, Random, 95% CI)	‐0.63 [‐0.98, ‐0.28]

2 Clinically significant depressive symptoms Show forest plot	1	24	Risk Ratio (M‐H, Random, 95% CI)	0.33 [0.04, 2.77]

3 Anxiety Show forest plot	1	78	Mean Difference (IV, Random, 95% CI)	‐7.5 [‐13.11, ‐1.89]

4 Carer burden Show forest plot	3	135	Std. Mean Difference (IV, Random, 95% CI)	0.24 [‐0.11, 0.58]

5 Coping style Show forest plot	1	19	Mean Difference (IV, Random, 95% CI)	6.0 [‐4.59, 16.59]

6 Dropout rates Show forest plot	4	166	Risk Ratio (M‐H, Random, 95% CI)	1.39 [0.32, 5.99]

Comparison 1. MBSR versus active control immediately postintervention

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Comparison 2. MBSR versus inactive control immediately postintervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Depressive symptoms Show forest plot	2	50	Mean Difference (IV, Random, 95% CI)	‐1.97 [‐6.89, 2.95]

2 Clinically significant depressive symptoms Show forest plot	1	33	Risk Ratio (M‐H, Random, 95% CI)	0.69 [0.26, 1.78]

3 Anxiety Show forest plot	1	33	Mean Difference (IV, Random, 95% CI)	‐7.27 [‐14.92, 0.38]

4 Carer burden Show forest plot	1	17	Mean Difference (IV, Random, 95% CI)	‐1.60 [‐19.48, 16.28]

5 Coping style Show forest plot	1	17	Mean Difference (IV, Random, 95% CI)	7.90 [‐5.41, 21.21]

6 Dropout rates Show forest plot	1	20	Risk Ratio (M‐H, Random, 95% CI)	2.0 [0.21, 18.69]

Comparison 2. MBSR versus inactive control immediately postintervention

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Comparison 3. MBSR versus active control within 3‐month follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Depressive symptoms Show forest plot	1	38	Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.71, 0.39]

2 Carer burden Show forest plot	1	38	Mean Difference (IV, Random, 95% CI)	6.62 [‐4.92, 18.16]

Comparison 3. MBSR versus active control within 3‐month follow‐up

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Comparison 4. MBSR versus inactive control within 3‐month follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Depressive symptoms Show forest plot	1	31	Mean Difference (IV, Random, 95% CI)	‐3.0 [‐8.52, 2.52]

2 Clinically significant depressive symptoms Show forest plot	1	31	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.20, 1.49]

3 Anxiety Show forest plot	1	31	Mean Difference (IV, Random, 95% CI)	‐6.92 [‐14.60, 0.76]

Comparison 4. MBSR versus inactive control within 3‐month follow‐up

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Comparison 5. MBSR versus active control within 3‐ to 6‐month follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Depressive symptoms Show forest plot	1	78	Mean Difference (IV, Random, 95% CI)	‐3.20 [‐6.80, 0.40]

2 Clinically significant depressive symptoms Show forest plot	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.25, 4.00]

3 Anxiety Show forest plot	1	78	Mean Difference (IV, Fixed, 95% CI)	‐6.5 [‐12.00, 1.00]

4 Carer burden Show forest plot	1	78	Mean Difference (IV, Fixed, 95% CI)	0.90 [‐0.55, 2.35]

Comparison 5. MBSR versus active control within 3‐ to 6‐month follow‐up

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Mindfulness‐based stress reduction for family carers of people with dementia

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