REVIEW

Mindfulness Interventions Deliveredby Technology Without Facilitator Involvement: What ResearchExists and What Are the Clinical Outcomes?

James Fish1& James Brimson2

& Siobhan Lynch3

Published online: 2 June 2016# The Author(s) 2016. This article is published with open access at Springerlink.com

Abstract New cost-effective psychological interventions areneeded to contribute to treatment options for psychiatric andphysical health conditions. This systematic review aims toinvestigate the current literature on one potentially cost-effective form of mindfulness-based therapy, those deliveredthrough technological platforms without any mindfulness fa-cilitator input beyond the initial design of the programme.Three electronic databases (Ovid Medline, PsychINFO andEmbase) were searched for relevant keywords, titles, medicalsubject headings (MeSH) and abstracts using search termsderived from a combination of two subjects: ‘mindfulness’and ‘technology’. Overall, ten studies were identified. Themajority of studies were web-based and similar in structureand content to face-to-face mindfulness-based stress reductioncourses. Clinical outcomes of stress (n=5), depression (n=6)and anxiety (n = 4) were reported along with mindfulness(n=4), the supposed mediator of effects. All eight studies thatmeasured significance found at least some significant effects(p< .05). The highest reported effect sizes were large (stressd=1.57, depression d= .95, both ps> .005). However, meth-odological issues (e.g. selection bias, lack of control groupand follow-up) which reflect the early nature of the workmeanthese largest effects are likely to be representative of maximalrather than average effects. Whilst there are important

differences in the construction, length and delivery of inter-ventions, it is difficult to draw firm conclusions about the mosteffective models. Suggestions of key characteristics are madethough, needing further investigation preferably instandardised interventions. Given the existing research andthe speed at which technology is making new platforms andtools available, it seems important that further research ex-plores two parallel lines: first, refinement and thorough eval-uation of already established technology-based mindfulnessprogrammes and second, exploration of novel approaches tomindfulness training that combine the latest technological ad-vances with the knowledge and skills of experienced medita-tion teachers.

Keywords Mindfulness .Meditation . Technology .

Web-based . Systematic review . Facilitator . Clinical .

Technological platform . Online .MBSR .MBCT

Introduction

There is now a great deal of evidence supporting mindfulness-based interventions in reducing clinical features of depression,anxiety, stress and psychological components of pain along-side increases in well-being (Bohlmeijer et al. 2010; Chiesaand Serretti 2009; Chiesa and Serretti 2011; Grossman et al.2004; Ledesma and Kumano 2009; Marchand 2012; Piet andHougaard 2011). The two most popular programmes aremindfulness-based stress reduction (MBSR; Kabat-Zinn1982) and mindfulness-based cognitive therapy (MBCT;Segal et al. 2002). Meta-analyses show moderate within-group effect sizes on clinical features associated with commonpsychological disorders (ES≈ .5; e.g. Chiesa and Serretti2011; Fjorback et al. 2011; Khoury et al. 2013).

* James FishJames.fish@kcl.ac.uk

1 Academic Centre, Faculty of Life Sciences and Medicine, 1st Floor,Henriette Raphael Building, Guy’s Campus, London SE1 1UL, UK

2 Institute of Psychiatry, Psychology and Neuroscience, King’sCollege London, 16 De Crespigny Park, London SE5 8AF, UK

3 Medical Education, Faculty of Medicine, University ofSouthampton, England, UK

Mindfulness (2016) 7:1011–1023DOI 10.1007/s12671-016-0548-2

The quality of the training provided by mindfulnessteachers is considered crucial to the overall success of a mind-fulness training programme (Crane et al. 2010). Up until re-cently, the majority of mindfulness teachers were, as Craneet al. (2012) describe it, first- or second-generation teacherswho were either taught by Jon Kabat-Zinn or his colleagues,or learning from those who had. This is changing now andincreasing numbers of mindfulness trainers are teaching withlimited experience. In order to provide some benchmark forprogrammes, the UK Network of Mindfulness-Based TeacherTrainers (2011) provide an outline of the core experience andcompetencies which are considered an essential basis forteaching mindfulness. This includes teachers having asustained and consistent personal mindfulness practice.Given the growing popularity of mindfulness-based ap-proaches along with the extensive commitment and experi-ence required to teach it, there is currently a tension betweenlimited supply and increasing demand. There are concerns thatin the rush to meet demand, it is possible that the integrity andauthenticity of the work may be diminished if delivered byinexperienced teachers (Crane et al. 2012).

There is unlikely to be one single way to address this issue;however, one approachmight be the delivery of well-designedmindfulness training online, using web-based programmes,mobile apps and other technological platforms. Internet-based interventions are by no means new (e.g. Barak et al.2008; Taylor and Luce 2003); some are even well-established.Computerised cognitive behavioural therapy (cCBT), for ex-ample, is supported in the UK for use with mild to moderatedepression and anxiety by the National Institute for Health andClinical Excellence (National Institute of Clinical Excellence2006). During cCBT, patients login to a secure website atspecific time points in order to access and read content online.Content is generally arranged in a series of eight lessons ormodules and can take the form of a website or even a smart-phone application (Andersson and Titov, 2014). Overall, thereis evidence supporting use of such interventions for majordepression, panic disorder, social phobia or generalised anxi-ety disorder, with a moderate mean within-group effect size of.88. (Andrews et al. 2010). However, there are a number ofissues with these interventions. Drop-out rates can be high(range 3–34 %) and, as a recent meta-analysis suggested, ef-fects may not be sustained into follow-up (So et al. 2013).Additional therapist support appears to be more effective thanthose without (ES=1 vs .2; Spek et al. 2007) and reduceattrition rates (So et al. 2013), so there is some loss of effec-tiveness when direct contact with a therapist is lost.

By removing face-to-face contact with an experiencedmindfulness teacher, interventions have the potential to bemore cost-effective, accessible, and flexible. This needs tobe balanced against the potential reduction in quality and ul-timately effectiveness. Extensive research is therefore neededbefore such interventions can be supported for use in a clinical

environment. It is clear that these interventions could be pop-ular with participants. Commercial mindfulness training fromwebsites and mobile apps (e.g. Headspace and Buddify) alongwith books with audio files is increasingly popular, and thereis a growing public interest in mindfulness training online andusing smart phones. Most of these products do not have anyfacilitator involvement beyond their initial design and manyare similar to the interventions included in this review. Thismay offer cost-effective interventions with a huge potential forscalability after initial design.

This review explores the current research into mindfulnesstraining interventions delivered on technological platformsthat do not have direct facilitator involvement. We take a firstlook at whether such programmes are beneficial for partici-pants and lead to changes to clinical outcomes such as stress,anxiety and depression which are consistent with the broaderliterature on mindfulness interventions.

Method

Three databases (Ovid Medline, PsychINFO and Embase)were searched for relevant keywords, titles, medical sub-ject headings (MeSH) and abstracts. Each database wassearched up to the 6 July 2014. Two search strings weredeveloped: (1) ‘mindfulness’ and (2) ‘technology’.Inclusion criteria were as follows: (1) the study interven-tion must teach formal mindfulness techniques (for exam-ple sitting and moving meditation as compared to informalmindfulness exercises such as being mindful of day to dayactivities), (2) the mindfulness training must be taught viatechnology only, (3) the study must include clinical out-comes, (4) the intervention must not include direct facili-tation, (5) the paper must be available in full, and (6) itmust be written in English. The titles and abstracts ofidentified studies were screened by two screeners (JFand JB). Disagreements were discussed. Data was extract-ed from the remaining papers using an electronic dataextraction sheet. Any missing or unclear data was markedas such.

A PRISMA flow diagram for this review demonstrates theprocess (see Fig. 1; Moher et al. 2009). Two thousand eighty-nine papers were initially identified after duplicates and non-English papers were removed. One thousand four hundredeighty-two papers were excluded after a title search, clearlyon a different subject. A further 532 papers were excludedfollowing abstract reading, clearly on a different subject.Sixty-five papers were then excluded after a full text review.Of these, 24 were not technology-delivered, 22 were not pub-lished research, 14 were not interventions and four were notmindfulness interventions. Nine studies remained. One paperthat was in press was subsequently added (Dimidjian et al.2014). This led to a total of 10 studies being included.

1012 Mindfulness (2016) 7:1011–1023

Results

Study Characteristics

Table 1 includes a summary of study characteristics. Nine of10 studies were quantitative (Glück and Maercker 2011;Krusche et al. 2012; Altschuler et al. 2011; Krusche et al.2013; Davis and Zautra 2013; Cavanagh et al. 2013;Boettcher et al. 2014; Dimidjian et al. 2014; Reid 2013).This included five RCTs (Glück and Maercker 2011; Davisand Zautra 2013; Cavanagh et al. 2013; Dimidjian et al. 2014;Boettcher et al. 2014) and four feasibility evaluations withoutcontrols (Altschuler et al. 2011; Krusche et al. 2012; Kruscheet al. 2013; Reid 2013). No quantitative studies used the samesample although the qualitative study (Boggs et al. 2014) ex-plored participant views following an intervention used inanother quantitative study (Dimidjian et al. 2014).

Participant numbers ranged from 15 (Reid 2013) to 273(Krusche et al. 2013). Exclusion criteria were used in threestudies: these included high levels of psychiatric disorder(Glück and Maercker 2011), symptoms consistent with cur-rent substance misuse (Dimidjian et al. 2014) and a history ofmore than five episodes of depression (Davis and Zautra2013). Inclusion criteria were used in three studies: these in-cluded meeting diagnostic criteria for one of a number of

psychiatric disorders (Boettcher et al. 2014) and a history ofat least one major depressive episode (Dimidjian et al. 2014;Boggs et al. 2014).

The participants were all over 18 years of age; mean agesvaried from 25 to 56 years. A gender bias was evident asfemale participants made up between 71 and 98 % of partic-ipants; this is similar to face-to-face interventions (e.g.Fjorback et al. 2011). The majority of studies used studentsor the general populations although more specific populationswere studied which included patients with cancer (Altschuleret al. 2011), fibromyalgia (Davis and Zautra 2013) and indi-viduals with recurrent depression (Dimidjian et al. 2014;Boggs et al. 2014).

Intervention Characteristics

Table 1 includes a summary of intervention characteristics.Nine of the 10 programmes were primarily web-based, oftenwith audio CDs with recordings of meditations). Altschuleret al. (2011) however used audio CDs only. The duration ofthe interventions ranged from 13 days (Glück and Maercker2011) to 12 weeks (Altschuler et al. 2011). The total timecommitment asked from participants was not always clearbut where measured varied from three to 20 h. What practiceof outside the main sessions was not clear in most studies. All

Records identified through database searching

(n=2089)

Additional records identified through other sources

(n= 1)

Records after duplicates non-English papers removed

(n=607)

Records screened(n=607)

Records excluded(n=532)

Full-text articles assessed for eligibility

(n=75)

Full-text articles excluded, with reasons

(n=65)

1. Not delivered by technology (n=24)

2. Not published (n=22)

3. Not interventions (n=(14)

4. Not mindfulness intervention (n=5)

Studies included in qualitative synthesis

(n=10)

Fig. 1 PRISMA flow diagram ofmindfulness interventionsdelivered through technologywithout facilitator involvement(Moher et al. 2009)

Mindfulness (2016) 7:1011–1023 1013

Tab

le1

Summaryof

participantand

interventio

ncharacteristics

Study

Modeof

deliv

ery

Control

Population

Effects

measured

Interventio

ngroup

characteristics

N(at

start)

Coursetim

ing

Materials

Techniques

Rem

inders

Attrition

(%)

Meanage

(SD/

range)

Sex

(F%)

Course

duratio

nTo

taltim

ecommit-

ment

(excluding

home

practice)

Hom

epractice

(Instructio

n:Measured)

Glück

and

Maercker

(2011)

Web-based

Wait-list

Students

Depression,

mindful-

ness,stress

33.7(12.7)

71.4

4913

days

4h20

min

(13×20

min)

–Writtentext,

audiofiles,

flash

anim

ation

exercise

Awarenessof

bodily

sensations,

attentionof

breath,

acceptance

ofem

otions

Emails

(before,

halfway

andafter

second

module)

10.2

Krusche

etal.

(2012)

Web-based

-Students

Stress

48(11.25)

74100

4–8weeks

(participant

chooses

pace)

Unclear

30-m

inform

al+-

variable

inform

alexercise

per

week:

33%

‘every/m

ost

days’;55

%‘som

etim

es’;

12%

‘rarely’

Audio,

instruction-

alvideos,e-

learning

Bodyscan,

mindful

movem

ent,

inform

alexercises

Emails

-

Altschuler

etal.(2011)

Audio

CD’s

-Cancer

patients

Anxiety,

depression

56(31.70)

9123

12weeks

20h

5days/week,20

min

each:A

v.of

39(4-60)

listens

toaudio

CD

Audio

CDs,

studydiary

Awarenessof

breathing,

body

scan,

loving

kindness

Phonecalls

(3xa

month)

48

Krusche

etal.

(2013)

Web-based

-Students

Anxiety,

depres-

sion,stress

47.7 (11.98)

78273

4-8weeks

(participant

chooses

pace)

Unclear

130-m

inform

al,

1inform

alex-

ercise

per

week:;4

1%

‘every/m

ost

days’;52

%‘som

etim

es’;7

%‘rarely’

Audio,

instruction-

alvideos,

e-learning

Bodyscan,

mindful

movem

ent,

inform

alexercises

Emails

-

Davisand

Zautra.

(2013)

Web-based

Health training

Patientswith

fibrom

yal-

gia

Depression,

stress

46.14

(22.81)

9879

6weeks

3h (1

2×15

min)

–Visual

presenta-

tionof

text,

anim

ation

andaudio

Awareness

and

acceptance

ofem

otions

-15

Cavanagh

etal.(2013)

Web-based

Wait-list

University

students

Mindfulness,

stress

25.28

(6.85)

90.7

104

2weeks

Unclear

10minsdaily

:61

%>1/day;

87%

>1/week;

4%

none

Mindfulness

education,

audio,daily

journal

Mindfulness

ofbody,

breath,

thoughts

and

feelings

Emails

(every

3days)

52.3

Web-based

TAU

73200

8weeks

Unclear

–24

1014 Mindfulness (2016) 7:1011–1023

Tab

le1

(contin

ued)

Study

Modeof

deliv

ery

Control

Populatio

nEffects

measured

Interventio

ngroup

characteristics

N(at

start)

Coursetim

ing

Materials

Techniques

Rem

inders

Attrition

(%)

Meanage

(SD/

range)

Sex

(F%)

Course

duratio

nTo

taltim

ecommit-

ment

(excluding

home

practice)

Hom

epractice

(Instructio

n:Measured)

Dim

idjian

etal.(2014)

a

Individuals

with

recurrent

depression

Anxiety

depres-

sion,

mindful-

ness

47.40

(11.43)

Min

6days

practiceper

week:

Av.

11.25h

practising

Video

ofinteractions

between

instructors

and

partici-

pants,

audiofiles

Sitting meditation,

body

scan,

yoga,

inform

alpractices,

3-min

breathing

space

Boettcher

etal.(2014)

Web-based

Discussion

forum

General

publicwith

features

ofanxietyor

depression

Anxiety,

depression

37(8.9)

75.6

918weeks

16h

Twotim

esaday

for6days

per

week;

Not

measured

Introductory

video,

audiofiles,

psychoedu-

cation

Sitting meditation,

mindful

movem

ent,

body

scan,

breathing

anchor

exercises

–7.7

Reid(2013)

Web-based

-Occupational

therapy

students

Mindfulness

--

158weeks

Unclear

-Audio

files,

inform

a-tional

readings,

private

journal

Sitting meditation,

body

scan,

3-min

breathing

space,

mindful

movem

ent,

loving-

kindness,

qigong

––

Boggs

etal.

(2014)

aWeb-based

-Individuals

with

recurrent

depression

-46.89

(12.38)

71.1

-8weeks

Unclear

Minim

umof

6days

practice

perweek:

Not

measured

Video

ofinteractions

between

instructors

and

partici-

pants,

audiofiles

Sitting meditation,

body

scan,

yoga,

inform

alpractices,

3-min

breathing

space

–24

Hom

epracticeisunderstood

tomeanpracticeof

learnt

meditatio

ns

TAUtreatm

entasusual

aThese

studiesused

thesameinterventio

n

Mindfulness (2016) 7:1011–1023 1015

interventions introduced participants to some form of mind-fulness practice including body scans, mindfulness ofbreathing, mindful movement and loving kindness; somewere much more extensive than others though. Reminders topractice were used in five studies using phone calls(Altschuler et al. 2011) and emails (Glück and Maercker2011; Krusche et al. 2012; Krusche et al. 2013; Cavanaghet al. 2013).

Glück and Maercker (2011) used a web-based interventionaimed at reducing depression and stress along with increasingmindfulness in students. Over 13 days, participants wereasked to take a 20-min module every day except one, totalling4 h and 20 min. No mention of additional home practice wasnoted. Participant engagement was not measured. Writtentext, audio files and a flash animation exercise were used toteach and develop awareness of bodily sensations, mindful-ness of breath and ‘acceptance of emotions’. Attrition was10.2 %.

Krusche et al. (2012, 2013) used a web-based interventionaimed at reducing stress in students. The course ran for 4 to8 weeks, the pace directed by the participant. The total timecommitment was unclear. Home practice of one formal exer-cise lasting 30 min and one informal practice was asked forper week and participant engagement was measured; 12 and7 % of participants ‘rarely’ practising in the 2012 and 2013papers, respectively, all others doing exercises ‘sometimes’(55/52 %) or every/most days (33/41 %). A modular formatused instructional videos led by experienced mindfulness in-structors and e-learningmodules to teach a body scan, a sitting(it was unclear if this was akin to mindfulness of breath) andmindful movement meditations. Attrition rates were not statedand all statistical analysis was conducted with early com-pleters so it could not be calculated post hoc.

Altschuler et al. (2011) used audio CDs to deliver an inter-vention aimed at reducing anxiety and depression in cancerpatients receiving chemotherapy. The course ran over12 weeks and the time commitment was 5 days a week for20min a day, totalling 20 h. Participants averaged 39 listens tothe audio tracks, 13 h. The course consisted of two CDs re-corded by a mindfulness instructor who had been successfullytreated for cancer in the past: one CD was for patients tomeditate during chemotherapy and the other was to be listenedto at home. The tracks included awareness of breathing, abody scan and a loving kindness meditation. A reflective diarywas used to record thoughts and engagement. Attrition rateswere high at 48 %. Notably, this study did include one intro-duction session conducted in person. It was included in thereview, as the rest of the study did not include contact with agroup or facilitator.

Davis and Zautra (2013) used a web-based mindfulsocioemotional regulation intervention (MSER) aimed atreducing depression and stress in chronic pain patients. Thecourse ran over 6 weeks and included 12 modules which

lasted 15 min each, totalling 3 hours. The course consistedof written text, animations and audio to teach awareness andacceptance of emotions. Details of specific techniques orhome practice were not reported. The attrition rate was 15 %.

Cavanagh et al. (2013) used a web-based interventionaimed at reducing stress and increasing mindfulness in univer-sity students. The course ran over 2 weeks and consisted of10-min daily sessions, totalling 2 h 20 min. Audio files re-corded by clinical psychologists who had training and experi-ence with face-to-face mindfulness courses taught participantsmindfulness of breathing, body and thoughts and feeling sep-arately. The intervention also included a frequently askedquestions page, daily journal and study information. Homepractice was not noted. Attrition was 52.3 %.

Both Dimidjian et al. (2014) and Boggs et al. (2014) usedthe same intervention. Mindful mood balance (MMB),adapted fromMBCT, aimed to reduce anxiety and depressionwhilst increasing mindfulness in individuals with recurrentdepression. The intervention ran over 8 weeks and asked par-ticipants to practice for a minimum of 6 days a week for 20 mina day, totalling 16 h. Participants reported an average of 11.25 hout of a total of 16 possible hours. The course used videos ofinteractions between instructors and participants and audio filesto teach sitting meditations, body scans, yoga, 3-min breathingspace exercises and informal practice. Attrition was 24 %.

Boettcher et al. (2014) used a web-based intervention toreduce anxiety, depression and insomnia in members of thepublic with features of anxiety or depression. The interventionran over 8 weeks and asked participants to practice for 10 mintwice a day 6 days of the week. The course was organised intoeight modules with brief, instructive audio files teachingmindfulness of breathing, mindful movement and body scans.At the start of training, participants were presented with a 20-min educational video on mindfulness and anxiety. Attritionwas 7.7 %.

Reid (2013) study used a web-based intervention toincrease mindfulness in occupational therapy students. Thecourse ran for 8 weeks and appeared similar to MBSR incontent. The level of participation and engagement isunclear. The study stated that it expected students to spend a‘few hours a week’ on the intervention but further details ormeasurement was not noted. A private journal was used toenable students to document their reflections and concernsregarding their experiences in the previous week. Attritionrate was not noted.

Main Outcomes

Stress

Encouragingly three of the five studies that included well-validated stress measures reported moderate or large effects(see Table 2), d= .62 (Cavanagh et al. 2013), 1.20 (Krusche

1016 Mindfulness (2016) 7:1011–1023

Tab

le2

Interventio

neffectson

stress,depression,anxietyandmindfulness

measures

Study

Dose:practicelevel

(Reported)

Control

group

Measure

T1(baseline)

T2(post)

T3and4(FU)

Effectsizes

BG

WG

Glück

and

Maercker

(2011)

20min/day

(not

measured)

Waitlist

Stress

PSQ

40.06SD

=16.38

34.36

SD=15.06

7MFI

27.89

SD=11.18

I<C(T2):n

sT1>T2:

ns

Depression

SEK-27

2.70

SD=0.48

2.81 SD

=0.54

7MFU

3.00

SD=0.59

nsNs

PANASn

eg1.48

SD=0.93

0.96 SD

=0.70

7MFU

0.97

SD=0.48

nsd=.43**

Maintenance

unclear

PANASp

os2.53

SD=0.59

2.54 SD

=0.79

7MFU

2.93

SD=0.61

nsT1=T2

T2<T3:

d=0.43*

Mindfulness

FMI

37.04SD

=5.37

38.77

SD=6.46

41.16SD

=6.05

I=C(T2):n

sT1<T2:

d=0.32**

T2<T3:

t(27)=

1.980*

Krusche

etal.

(2012)

30min

onetim

eaweek

(33%

‘every/m

ost

days’;55

%‘som

etim

es’;12

%‘rarely’)

–Stress

PSS

23.04SD

=6.85

15.06

SD=6.42

13.45SD

=6.99

–T1>T2:

d=1.20**

T2>T3:

d=0.24**

Altschuler

etal.(2011)

20min

5days

aweek

(average

16)

–Depression

HADS-D

6.7norm

al4.5norm

al–

––

Anxiety

HADS-A

11.5CI9.9–13.0

6.7CI4.6–8.8

––

–Krusche

etal.

(2013)

30min

oetim

eaweek

(33%

‘every/m

ost

days’;55

%‘som

etim

es’;12

%‘rarely’)

–Stress

PSS

23.73SD=49.95

14.44

SD=45.86

1MFU

:13.45

SD=6.99

–T1>T2=T3:

d=1.57**

Depression

PHQ-9

10.06SD

=6.40

moderate

5.04 SD

=3.84

mild

1MFU

:4.30

SD=3.97

mild

–T1>T2:

d=.95**

Furtherim

provem

entat

1MFU

,d=.19**

Anxiety

GAD-7

10.98SD

=6.42

5.45 SD

=3.77

4.60

SD=3.72

–T1>2:

d=1.22**

T2>3:

d=.24*

Davisand

Zautra.

(2013)

15min

twotim

esaweek

Health training

Stress

Family

-related

stress

1.99

SD=1.01

––

I<C(T2):d

=.006?

–

Stress

Copingefficacy

3.12

SD=.96

––

I<C(T2):d

=.014?

–

Depression

Positiv

eandnegative

effect(Likert)

Positive:

2.29

SD=1.05

Negative

2.20

SD=0.92

––

Positiv

eI>

C(T2):

d=0.06*

NegativeI>

C(T2):

ns

PositiveT1>2:

unclearns

NegativeT1>2:

unclear**

Cavanagh

etal.(2013)

10mineveryday

(61%

>1/

day;87

%>1/week;4%

none)

Waitlist

Stress

PSS

21.70SD

=7.87

18.96

SD=6.75

–I<

C(T2):d

=.37**

T1<T2

d=0.42**

Mindfulness

FFMQ

117.76

SD=21.48

123.66

SD=20.16

–I>

C(T2):

d=0.27*

T1<T2

d=0.42**

Dim

idjian

etal.(2014)

20min

6days

aweek

(Average

1h20

min

aweek)

TAU

Depression

PHQ-9

4.21

SD=3.03

mild

/minim

al

2.89

SD=2.69

minim

al

10WFU

3.40

SD=3.01

minim

al6M

FU3.04

SD=2.53

I<C(T2):

d=0.78**

T1>T2:

r=0.27**

Maintainedat10W

and

6MFU

Mindfulness (2016) 7:1011–1023 1017

et al. 2012) and 1.57 (Krusche et al. 2013). In both of theirstudies, Krusche et al. group included only self-selected quickcompleters of the intervention in analysis; therefore, theseresults are likely to suggest the upper limits of effects. Twoother studies found small or non-significant effects (Davis andZautra 2013; Glück and Maercker 2011). There studies hadnotable issues with intervention and study design (e.g. smallparticipant numbers, less theoretical basis to intervention andunvalidated measures). Whether changes have a clinical cor-relates is difficult to determine as they do not translate easily.However, one study did look at the real significance of change(RCI) and found that, based on the perceived stress question-naire (PSQ), the intervention groupwas nine times more likelyto improve, based on a deviation from the mean of 1.96, com-pared to the waitlist group (Glück and Maercker 2011).Comparisons of the interventions to alternatives were madein three studies. The largest and highest quality study found amoderate difference between the intervention and a waitlist,d= .42 and p< .005 (Cavanagh et al. 2013). Other studies, ofpoorer quality, found very small or non-significant differencescompared to health training and waitlist (Glück and Maercker2011; Davis and Zautra 2013).

Depression

Three of the six studies including well-validated depressionmeasures reported statistically significant reductions withclear clinical correlates (Dimidjian et al. 2014; Boettcheret al. 2014; Krusche et al. 2013). Scores indicative of ‘mild’depression were reduced to ‘minimal’ (Dimidjian et al. 2014;Boettcher et al. 2014) and ‘moderate’ to ‘mild’ (Krusche et al.2013). Other studies were less indicative of real clinicalchange, but some did find reductions in depression scores.One study employed an unvalidated depression measure(Davis and Zautra 2013); another used a measure withoutguidelines in English (Glück and Maercker 2011). One studyused a validated measure but did not calculate significance(Altschuler et al. 2011). One study tested for real clinical in-dicators of change (discussed earlier) and found no significantchange on PANAS or SEK-27 measures that relate to depres-sion (Glück and Maercker 2011). With promising results, fourstudies compared the intervention to alternatives. Two studiesreported large and significant reductions in post-interventionscores compared to waitlists, d= .78 (Dimidjian et al. 2014)and d= .84 (Boettcher et al. 2014). Two studies found verysmall or non-significant effects of the mindfulness interven-tion compared to health training (Davis and Zautra 2013) andwaitlist (Glück and Maercker 2011).

Anxiety

The two studies which tested for significance on anxiety mea-sures found significant changes. These were large and haveT

able2

(contin

ued)

Study

Dose:practicelevel

(Reported)

Control

group

Measure

T1(baseline)

T2(post)

T3and4(FU)

Effectsizes

BG

WG

minim

alAnxiety

RSQ

45.12

SD=13.67

40.45

SD=15.11

––

T1<T2:

r=-23**

Mindfulness

FMI

126.52

SD=18.42

132.35

SD=18.42

––

T1<T2:

r=0.52*

Boettcher

etal.(2014)

20min

6days

aweek(not

measured)

Discussion

forum

Depression

BDI-II

16.4

SD=7.0

mild

6.5

SD=4.8

minim

al

6MFU

9.6

SD=8.2

minim

al

I<C(T2):d

=0.84*

T1>T2:

d=1.58**

Post<6M

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Anxiety

BAI

24.4

SD=8.6

11.8

SD=7.8

6MFU

:12.4

SD=6.7

T2:

d=.99**

T1>2:

d=1.33**

T1>T2:

d=1.44**

Reid(2013)

Not

reported

–Mindfulness

MAAS

51.73

SD=8.22

61.72

SD=5.44

––

T1<T2:

t=−4

.82**

Ccontrol,Iinterventio

n,FUfollo

w-up

*p<.05,**p<0.01

1018 Mindfulness (2016) 7:1011–1023

clear clinical correlates after interventions. Scores indicativeof ‘moderate/severe’ anxiety were reduced to ‘mild’(Boettcher et al. 2014) and ‘moderate’ to ‘mild’ (Kruscheet al. 2012). Another study found an average reduction from‘mild/moderate’ to ‘normal’ but did not test significance(Altschuler et al. 2011). A significant reduction in ruminationwas noted in one study although size or clinical correlationwas omitted (Dimidjian et al. 2014). One study compared anintervention to an alternative (a discussion forum) and found alarge difference (d= .99, p<0.01; Boettcher et al. 2014)

Mindfulness

All four studies including a mindfulness measure foundsignificant increases. Changes ranged statistically fromsmall to moderate in size on the FFMQ (Cavanaghet al. 2013) and the FMI (Glück and Maercker 2011;Dimidjian et al. 2014). One study found a significantincrease the MAAS that was not sized (Reid 2013).Note that some studies investigated other effects butthey have not been included in this review (e.g.insomnia in Boettcher et al. 2014).

Longevity of Effects

Two of the studies explored continued practice of mind-fulness after the intervention ended. One study reportedthat at 3-month follow-up, 50 % of participants continuedto practice when they felt stressed and 25 % maintainedregular practice (Glück and Maercker 2011). Anotherstudy found that 83 % of participants reported that theyintended to continue practice on a regular basis (Cavanaghet al. 2013). In many studies, effects either lasted intofollow-up or even further increased. Stress reduction wasmaintained or further reduced in all three studies whichinvestigated this: maintained at 1 and 3 months (Kruscheet al. 2012; Glück and Maercker 2011) and further re-duced at 1 month (Krusche et al. 2013). Continued effectson depression measures were present in three of four stud-ies which investigated this. Two studies had maintainedeffects at 6 months (Boettcher et al. 2014; Dimidjian etal. 2014) and one a further small significant decrease at1 month (Krusche et al. 2013). Conversely, one studyfound no effect present at 6 months (Glück andMaercker 2011). Effects on anxiety appear to last untilat least a month after intervention, although only twostudies conducted follow-up analyses. Reductions weremaintained at 6 months in one study (Boettcher et al.2014) and even further reduced at one month in another(Krusche et al. 2013). The only study which included afollow-up measure for mindfulness found a marginallysignificant further increase in scores at 7 months (Glückand Maercker 2011).

Attrition, Participation and Engagement

It is clear that participants did not always fully commit to theprogrammes, either engaging less than instructed or evendropping out. The reasons for this are unclear. Levels of‘home practice^ (that outside of first teaching of a technique)varied from none (noted) up to 20 min a day. The largesteffects were found in the Krusche et al. studies which encour-aged 30 min once a week of formal practice plus an informalexercise (many participants achieving more than this), but asmentioned earlier due to study design flaws, these are likely torepresent the maximal effects. As one would expect, studieswhich conducted statistical analyses with only participantswho completed the intervention with a high degree of partic-ipation and engagement (Krusche et al. 2012; Krusche et al.2013; Dimidjian et al. 2014) found greater effects on out-comes than those that did not. Longer course completiontimes, suggestive of less participation and engagement, corre-lated with weaker effects on outcome measures in one study(Krusche et al. 2013). Specifically, informal practice (i.e. in-tegration of mindfulness into daily activities), but not formal(e.g. sitting meditations), was correlated with those outcomes.Reported attrition rates ranged from from 52.3 % (Cavanaghet al. 2013) to 7.7 % (Boettcher et al. 2014). Both of thesecourses were similar and that was a reflection of the lack ofclear differences between courses that were better at retainingparticipants. Interestingly, Glück and Maercker (2011) foundthat participants with higher levels of initial distress were lesslikely to drop out.

Participant Feedback

Three studies measured the subjective benefit of participationwith broadly positive findings. In one study, training was‘beneficial’ for 73.5 % of participants after the interventionsand 66.6% at 3-month follow-up agreed. A total of 70.3% feltthe intervention ‘helped inner balance’ and 77.2 % would‘recommend’ the web-based training (Glück and Maercker2011). Another study reported that 87 % of participantsthought the programme was ‘at least some benefit’ although13 % thought it was ‘no benefit at all’ (Cavanagh et al. 2013).Altschuler et al. (2011) reported that participants were ‘verypositive’ about participation and perceived that the interven-tion helped them ‘cope better with diagnosis and treatment’,although no further details were given.

Only one study gives us some insight into participant ex-perience of an intervention. The qualitative study (Boggs et al.2014) included in this review can highlight what may bestrengths of existing interventions along with potential im-provements. The Boggs et al. (2014) study used MBCT as abasis for its online modular format and identified four themesin participant responses: evidence of concept comprehension,home practice, MBCT web content, and MBCT web-based

Mindfulness (2016) 7:1011–1023 1019

group process. All of the participants seemed to grasp whatmindfulness was and found an overall positive impact of theintervention. Many gave practical examples of putting learntconcepts into practice. Participants noticed an increased sen-sitivity to personal warning signs of imminent depressive re-lapse and successfully implemented mindfulness practices tocounteract these symptoms. Time constraints and lack of mo-tivation were reported to prevent completion of the recom-mended home practice at times. Many aspects of the interven-tion were positively received. The modular e-learning formatof the programme was clear and text outlined key concepts inan effective manner. Participants spoke very highly of thevideos of group leaders speaking. This was perceived as agood alternative to written text for some individuals. Audiorecordings of guided meditations were perceived as helpful,and most stated they would use them in the future. Someaspects of the intervention were not perceived positively bysome participants: particular mediations, especially the bodyscan, practice requirements (30 min from the start) and anabsence of an instructor or group. Some alternative ap-proaches were suggested such as starting on 15 min and grad-ually increasing practice requirements. One programme is notlikely to fit all participants. For example, in opposition toothers, a small number of participants stated they were not‘group learners’. The group videos seemed to be an adequatealternative for many of the participants, who felt that they gotto know the group in the videos.

Discussion

Although research is in its infancy, this review lends someinitial support to mindfulness interventions using technologi-cal platforms to deliver mindfulness training without directfacilitator input. Reduction in clinical features of anxiety, de-pression and stress was found in a number of studies. Anxietyand depression effects were comparable in size to NICE rec-ommended cCBT (Andrews et al. 2010) along with face-to-face mindfulness interventions (within group ES ≈ .5; e.g.Chiesa and Serretti 2011; Fjorback et al. 2011; Khoury et al.2013). Effects appear to last into follow-up, even increasedfurther in one study at 1-month post-intervention. Despite en-couraging findings, firm conclusions about effectiveness can-not be made yet.

Criticisms of cCBT that dropout rates can be high andeffects may not be sustained (So et al. 2013) support the needfor research into other interventions like those reviewed whichmay produce longer lasting effects and lower attrition rates.The mindfulness interventions included had a wide range indropout rates (7.7-52.3 %) so cannot currently be favourablycompared to cCBT in terms of attrition. However, there isinitial support for the longevity of stress, anxiety and depres-sion reduction effects. Not only were continued effects seen in

the majority of studies which measured this but also one studyeven found further effects after 1 month. Notably, this studywas subject to multiple biases in its design, using fast com-pleters only in analysis. Longevity of effects may be due to thenature of mindfulness interventions which teach the use ofcontinued formal and informal practice n a way that CBT doesnot.

Participation, engagement and attrition are all likely to playan important role in outcomes and mediate effects. A dose-response relationship may even exist although the evidence sofar is not strong enough to support this. One finding byKrusche et al. (2012) that longer course completion timescorrelated with weaker effects on outcome measures supportsthis. Specifically, the contribution of informal but not formalpractice lies in opposition to a previous study by Carmody andBaer (2008) who found no significant relationship betweeninformal practice and outcomes in their review of face-to-face interventions.

Participant and intervention characteristics are likely toboth contribute to effects. Whether participant characteristicsled to greater effects in certain interventions is largely unclearalthough one study found that participants with higher levelsof initial distress had lower attrition rates (Glück andMaercker 2011). Participants that urgently require help maybe more likely to actively engage with practice and gain great-er effects. Unfortunately, none of the studies investigated whypeople left studies. Course length and time commitment, en-couraged daily practice, meditations taught (e.g. body scans,mindfulness of breathing and mindful movement) and typesof resources (e.g. text, audio, videos and workbooks) all var-ied between studies and there is no clear link between theseand outcomes. Despite the lack of clear support for one par-ticular model though, shared characteristics, especially be-tween the more successful interventions, do suggest a tem-plate on which future interventions should be based. The qual-itative study found that participants liked many of the ele-ments shared between interventions, particularly the web-based, modular e-learning format that used different types ofcontent such as text, audio and videos. Animations were lesspopular.

Whilst these programmes do not include direct facilitatorcontact with participants, it is important to recognise the roleof those who designed the programme and prepared the coursematerials. Experience of those who designed the course wasnot mentioned in most papers but this is also likely to play animportant role. Given that quality of the training is thought tobe crucial to the effectiveness of face-to-face mindfulnesstraining (Crane et al. 2010), it stands to reason that thoseinvolved in an online programme are just as, if not more,important as the trainer in a face-to-face mindfulness interven-tion. Programme developers are doing two things, developinga targeted teaching programme for a given population andthen deciding the best way to communicate and deliver that

1020 Mindfulness (2016) 7:1011–1023

using technology. Recently, the UK Network of Mindfulness-Based Teacher Trainers (2011) developed good practiceguidelines for those delivering mindfulness training face-to-face. It seems important that the conversation now extends tothe development and delivery of mindfulness programmesonline, learning programmes, and fully online trainingprogrammes.

One concern about technology delivered mindfulnessprogrammes such as those reviewed is that the integrity andauthenticity of the teachings will necessarily be compromisedgiven the lack of face-to-face contact with a facilitator. Thisreview found evidence that interventions can teach mindful-ness and maintain faithfulness to accepted models. The qual-itative study included (Boggs et al. 2014) went some way toshow that it is at least possible for such interventions to teachthe core elements of face-to-face courses. For example, par-ticipants here stated that they were better at coming out of‘autopilot’ and ‘slowing down’ along with re-framing nega-tive thoughts and identifying triggers for anxiety and depres-sion. Quantitative support comes from all four studies thatassessed mindfulness which reported increases in mindful-ness. There at the very least exists a correlation between clin-ical effects and mindfulness levels.

It is vital that we learn how to make interventions moreeffective, and one way to do this may be by encouraging morepractice. Practice times were short across the studies and nointerventions encouraged or achieved levels of practice seenon a face-to-face MBSR/CT course (40 min a day). However,participants in the qualitative study have noted that the amountof time encouraged (30min) is toomuch, especially at the startof the intervention (Boggs et al. 2014). This may explain someof the attrition. Notably, many studies found comparable ratesto those found with face-to-face interventions (16.5 %;Khoury et al. 2013). Shortening practice times may achievelower attrition rates and more participation and engagement,but they may also reduce the effectiveness of the intervention.One way forward might be to encourage multiple shorter ses-sions throughout the day building on the 3-min breathingspace included in many programmes already. Another optionmay be to gradually increase time commitment as suggestedby participants in Boggs et al. (2014).

Moving forward, research is likely to follow two distinctpaths. The first of which is to build on the initial support forthe effectiveness of technology-delivered mindfulness inter-ventions without direct facilitator input. This should also in-clude an understanding of mechanisms behind effective inter-ventions. A standardised intervention format would allow forrobust, large-scale quantitative evaluations and adaptationsincluding novel approaches. Previous interventions and quan-titative study suggest elements which should be used in thefuture including a modular course structure, use of differentmaterials within the same course (e.g. text, audio, videos andprintouts) and an e-learning environment. The importance of

many key elements such as course length, practice time, ma-terials used, techniques taught and course designer experienceare still not well understood, and comparisons between other-wise standardised interventions would elucidate the impact ofthese elements. This approach also allows specific interven-tions focus on particular issues (e.g. addiction, depression andeating disorders). An approach incorporating standardisationand specific focus of interventions is similar to that seen in theface-to-face MBSR/MBCT community (e.g. Kristeller andWolever 2011; Sibinga et al. 2011; Salmoirago-Blotcher etal. 2012; Reid 2013). High-quality supporting research isneeded.

This review recommends a number of components to astandardised intervention model: courses should last at least4 weeks; 30 min of practice for 6 days a week should be en-couraged although variations on this should be explored; theuse of a wide range of materials (e.g. audio, video and text),development find experiencedmindfulness practitioners shoulddevelop courses; core mindfulness exercises should be taught(i.e. mindfulness of breathing andmovement, body scans). Thisreview also recommends a number of components to futureresearch models: conducting intention-to-treat analyses, com-paring interventions against appropriate control groups (e.g.cCBT or face-to-face mindfulness interventions), measuringmindfulness as a mediator, including follow-up measures upto at least 6 months, measuring individual practice levels anddrop-out rates and including exploration of participants’ expe-riences, especially their understanding of mindfulness and whysome participants drop out or do not fully engage. A limitednumber of well developed programmes must be comprehen-sively evaluated before widespread use.

The second research focus should be experimentationwith novel approaches including integration of interven-tions with face-to-face programmes and varying degreesof instructor-led or group work through technology. Theuse of mobile technology may offer an innovative wayto encourage practice. Many existing interventions al-ready included reminder emails. Building on this, mo-bile technology could also be used to monitor and en-courage home practice. Like web-based delivery, it islow cost and flexible. Use of new technologies suchas mobile apps and even integration of technology intoestablished programmes could create more effective in-terventions. Although some of the advantages of a self-contained intervention, such as low cost, scalability andaccessibility, may be lost, technology may be a usefuladdition to existing face-to-face interventions within ablended learning environment. This would satisfy theneed that some participants, but notably not all, havefor facilitator and group interactions. Another approachmay be to have groups that meet to share in onlinedelivery of interventions designed by experiencedteachers, perhaps even with live video links.

Mindfulness (2016) 7:1011–1023 1021

Limitations

Caution should be taken before any conclusions on effective-ness of these interventions are made. Some studies had smallor insignificant measured effects and the studies with largereffects had a number of methodological weaknesses. Kruscheet al. (2012, 2013) found the largest effects but shared meth-odological flaws with other studies that prevent more generalsupport of these interventions being made (other studies ref-erenced in brackets). Krusche et al. used completers only inanalysis (Boggs et al. 2014) and lacked follow-up (Cavanaghet al. 2013; Reid 2013; Davis and Zautra 2013) and perhapsmost importantly, they did not have a control group(Altschuler et al. 2011; Reid 2013). No studies used a similarintervention (e.g. cCBT, counselling or face-to-face mindful-ness interventions) as a control which is another major limita-tion of research so far. The high proportion of women alongwith clinical or student populations in study groups may alsolimit generalisability. This review does not include a meta-analysis so overall effects, including those of potential medi-ating variables, have not been calculated.

Compliance with Ethical Standards

Funding This study received no funding.

Conflict of Interest The authors declare that they have no conflict ofinterest.

Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you give appro-priate credit to the original author(s) and the source, provide a link to theCreative Commons license, and indicate if changes were made.

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