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Literature Review

O R I G I N A L R E S E A R C H

Effects Of Modified Mindfulness-Based Stress

Reduction (MBSR) On The Psychological Health

Of Adolescents With Subthreshold Depression:

A Randomized Controlled Trial
This article was published in the following Dove Press journal:

Neuropsychiatric Disease and Treatment

Jia-Yuan Zhang
1,
*

Xiang-Zi Ji
2,
*

Li-Na Meng
1

Yun-Jiang Cai
1

1Department of Psychological Nursing

Science, Harbin Medical University,

Daqing, Heilongjiang Province, People’s
Republic of China; 2Department of

Nursing Science, Suzhou Vocational

Health College, Suzhou, Jiangsu Province,

People’s Republic of China

*These authors contributed equally to

this work

Background: Sub-threshold depression (SD) has been associated with impairments in

adolescent health which increase the rate of major depression. Researchers have shown the

effectiveness of mindfulness on mental health, however whether the traditional mindful skills

were suitable for youngsters, it was not clear. This study investigated the effects of a tailed

Mindfulness-based stress reduction (MBSR) on their psychological state.

Methods: A double-blind, randomized controlled trial was carried out. 56 participants who

met the inclusion criteria agreed to be arranged randomly to either the MBSR group (n=28)

or the control group (n=28). Participants in MBSR group received a tailored 8-week, one

time per week, one hour each time group intervention. The effectiveness of intervention was

measured using validated scales, which including BDI-II, MAAS, RRS at three times (T1-

before intervention; T2-after intervention; T3-three months after intervention). A repeated-

measures analysis of variance model was used to analyze the data.

Results: The results showed significant improvements in MBSR group comparing with

control group that depression level decreased after the 8-week intervention and the follow up

(F =17.721, p < 0.00). At the same time, RRS score was significantly decreased at T2 and T3

(F= 28.277, p < 0.00). The results also showed that MBSR promoted the level of mind-

fulness and the effect persisted for three months after intervention (F=13.489, p < 0.00).

Conclusion: A tailored MBSR intervention has positive effects on psychology health

among SD youngsters, including decrease depression and rumination level, cultivate

mindfulness.

Keywords: mindfulness, adolescent, subthreshold depression

Introduction
Subthreshold depression (SD), also known as subsyndromal depression, subclinical

depression, or mild depression, refers to a state or a subpopulation of individuals

who have certain depressive symptoms but do not meet the diagnostic criteria for

major depressive disorder.1 A previous study found that the incidence of subthres-

hold depression was significantly higher than that of major depressive disorders,

with an estimated prevalence rate of 25% worldwide, and it had a serious impact on

individual life and social psychological function.2 However, there is little agree-

ment on how to address the diagnosis of subthreshold depression; modern classi-

fication systems such as the Diagnostic and Statistical Manual of Mental Disorders,

Correspondence: Li-Na Meng; Yun-Jiang Cai
Department of Psychological Nursing
Science, Harbin Medical University, No. 39
XinYang Street, Daqing, Heilongjiang
Province 163319, People’s Republic of China
Email 2935855397@qq.com;
2622340324@qq.com

Neuropsychiatric Disease and Treatment Dovepress
open access to scientific and medical research

Open Access Full Text Article

submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2019:15 2695–2704 2695
DovePress © 2019 Zhang et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.

php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the
work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

http://doi.org/10.2147/NDT.S216401

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Fourth Edition (DSM-IV) have established diagnostic

categories for subsyndromal depressive symptoms, includ-

ing “dysthymia,” “brief recurrent depression,” and “minor

depressive disorder”.3 Subthreshold depression is consid-

ered to be the precurative stage of major depressive dis-

order and can predict the occurrence of major depressive

disorder in individuals in the future. It should be made

clear that it is increasingly recognized that individuals with

subthreshold depression do not have a similar prognosis to

those who are asymptomatic, and are in fact at elevated

risks of later depression and suicidal behaviors.4

Individuals with subthreshold depression have an odds

ratio of more than 5 for having a first lifetime episode of

major depression disorder.5 Meanwhile, subthreshold

depression has also increased the risk of adverse outcomes

such as drug abuse and dependence. In recent years, the

incidence of subthreshold depression in adolescents has

grown rapidly and as high as 36.56%.2 There are adoles-

cents with subthreshold depression who have not yet met

the diagnostic criteria for depression, but subthreshold

depression has caused a decline in their social function

and has placed them at a higher risk of experiencing

depressive episodes, which should be highly concerning.6

However, there are limited studies focus on investigating

an effective and feasible way to help adolescents with

subthreshold depression improve their psychological

health.

Mindfulness, derived from Buddhist meditation, is

described as a state of being purposeful and giving non-

judgemental attention to the present moment. Its core

elements are “the ability to focus on the present” and

“keep a curious, open and receptive attitude”.7

Mindfulness intervention is a psychological treatment,

which refers to a series of psychological training methods

based on “mindfulness,” that can help individuals cultivate

and enhance mindfulness. In the late 1970s, American

psychologist Kabat-Zinn introduced and developed mind-

fulness-based stress reduction (MBSR) psychotherapy,

which was praised as “the third wave of behavioral and

cognitive therapy”.8 MBSR is a systematic non-drug psy-

chological therapy that includes four basic mindfulness

skills. Through mindfulness meditations, body awareness

and yoga, MBSR can awaken inner mindfulness and

improve self-regulation to help people relieve stress. At

present, MBSR has been widely used in medical treatment

and has become an important part of the biopsychosocial

approach medical system to promote psychology and phy-

sical health.9 Studies have shown that MBSR can alleviate

anxiety and depression among cancer patients.10,11

A recent meta-analysis showed that yoga-based interven-

tions, including mindfulness practice, had significant ben-

eficial effects for pregnant women with mild depressive

symptoms.12 However, due to differences in cultural and

religious beliefs and economic levels, whether MBSR is

suitable for the Chinese adolescent population needs

further investigation.

Mindfulness therapy includes formal and informal tech-

niques. The traditional form of mindfulness-based stress

reduction therapy is group intervention. Each group is lim-

ited to approximately 30 people with 8 practice times of 2

to 2.5 hrs each.13 However, due to time constraints or hard-

to-grasp core skills, many people suspend or quit psycho-

logical treatment. For adolescents, due to their immature

psychological adjustment mechanism, it is difficult for them

to grasp the core of mindfulness skills related to meditation

in a short amount of time.14 The best way to perform

psychological intervention is to allow adolescents to apply

the techniques to their life and integrate them into their life

over time, thus improving their psychological health. Fewer

studies have focused on the longitudinal effects of mind-

fulness skills on adolescents in China.15 Therefore, a tai-

lored MBSR programme for adolescents with rigorous and

well-controlled randomized trials is needed to further test

the long-term effects of modified MBSR on the psycholo-

gical health of adolescents.

This study was designed to evaluate the effects of a

tailored simplified MBSR on the psychological health of

adolescents with subthreshold depression, including

depression levels, rumination and mindfulness levels, in

a randomized controlled trial. We hypothesized that mod-

ified MBSR training would provide evidence for improv-

ing psychological health, thus decreasing depression and

rumination levels and increasing mindfulness in Chinese

adolescents with subthreshold depression.

Methods
Study Design
This study was a randomized controlled design with dou-

ble-blind subjects. All participants were divided equally

into the MBSR training group and the control group using

the random number table by staff members who were

independent from the study. All participants received the

anonymous letters and they were blinded to their random

assignment until the end of the session. When the study

was completed, the control group received the same

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intervention according to their own wishes. The interven-

tion was conducted at the psychological interview room

carried out by a qualified psychologist. The anonymous

data were collected and analyzed by an assistant who was

blinded to the group assignment and all the trials. The

design of the entire study is illustrated in a flow diagram

in Figure 1.

Sample And Setting
The sample-size estimation in this study was calculated by

using the G*POWER version 3.1 program with a power

(1−β) of 0.80 in the paired-samples t-test and a signifi-

cance level of 0.05. Based on the related data,16 we estab-

lished an effect size (d) of 0.796; consequently, the total

sample size was 52 participants. Allowing for a 5–10%

dropout rate, we recruited 56 students in September 2017.

Participants were enrolled by putting up a poster on cam-

pus. We used two steps to recruit the participants. First, all

of the interested students completed questionnaires (Beck

depression inventory, BDI and self-rating depression scale,

SDS). Participants who had a BDI>14 and an SDS>53

were defined as the preliminary screening group. Second,

the structured clinical interview for DSM (SCID) was

conducted among the preliminary screening group by a

psychologist to perform the second screening. The exclu-

sion criteria were as follows: i) had recently suffered from

major stress events; and/or ii) had major depressive dis-

order, bipolar disorder or other types of mental illnesses. A

total of 291 students agreed to participate in the study, and

in the end, the study included 56 participants who met the

following inclusion criteria: i) volunteered for this study

and agreed to obey the rules during the intervention and ii)

had subthreshold symptoms of depression (as defined by

the questionnaires and structured interviews). Participants

who had participated in or were participating in similar

interventions (such as yoga or meditation) were also

excluded. All participants provided their written consent.

The study was approved by the institutional review board

at Harbin Medical University (Daqing) and this trial was

conducted in accordance with the Declaration of Helsinki.

Intervention
The MBSR Intervention Group

Participants allocated to the MBSR training groups

received 8 weeks of modified MBSR training. Based on

traditional MBSR theory, the intervention was tailored

according to the characteristics of adolescents and empha-

sized teaching them to apply formal techniques such as

body scanning, sitting meditation, and mindfulness yoga to

Figure 1 Study flow diagram: enrollment to analysis.

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all aspects of the practitioner’s life, including experiencing

the pleasant/sad moments in life, walking, sleeping, eating,

breathing and exercising to keep the attitude of “mind-

fulness”. The intervention plan was designed and adminis-

tered by a qualified psychological expert who has been

involved in MBSR treatment for 5 years. Participants in

the MBSR group were divided into 4 groups with 7 people

per group. Each group received training sessions for 8

weeks, and the sessions occurred once a week for one

hour at a time. Each session included 10 mins of free

talk (feeling about homework), 15 mins of demonstration

and explanation, 20 mins of practice and guidance, and

15 mins of group imitation training. Each session was

followed by homework, which was available for the trai-

ner to understand the practice situation of each person.

Combined with daily activity, the themes of the interven-

tion were derived from “eye”, “ear”, “nose”, “tongue”,

“body” and “thinking”. More details of each session are

listed in Table 1.

The Control Group

Students in the control group continued with their lives as

usual. No specific intervention was implemented in the

control group. To avoid possible overlap (contamination)

with components of the MBSR programme, the students in

the control group who planned to attend related associations

such as yoga clubs during the intervention period (8 weeks)

were excluded. After completion of the study, each student

in the control group was provided with the same MBSR

course according to their own wishes.

Measures
Beck Depression Inventory-II (BDI-II)

The primary outcome was the severity of depressive symp-

toms assessed with the BDI-II. The scale was a well-

validated and widely used measure of depression that

assesses the frequency of depressive symptoms over the

previous 2 weeks. It consists of 21 items that are rated on a

4-point scale, with scores ranging from 0 to 63, and cut-off

points of 0–13, 14–19, 20–28 and 29–63, which represent

no, mild, moderate and severe levels of depression, respec-

tively. The scale has been used in the Chinese adolescent

population, revealing good reliability and validity.17

Mindful Attention And Awareness Scale (MAAS)

Participants’ self-reported mindfulness level was measured

with the MAAS.18 The scale contains 15 items that assess

the most important characteristics of mindfulness. Items

are rated on a 6-point scale and scored as (1) almost

always to (6) almost never, with higher scores reflecting

a greater mindfulness state. The scale has been tested

among Chinese college students, revealing good internal

consistency reliability (α=0.85) and test-retest reliability

(r=0.54).19

Ruminative Response Scale (RRS)

The RRS was compiled by Nolen-Hoeksema and assesses

the response to depression. It consists of 22 items rated on

a 4-point scale that are scored as (1) never to (4) very

often, with scores that ranged from 22 to 88. Higher scores

represent a greater level of rumination. It has 3 factors:

symptom rumination, forced thinking and introspection.

The Chinese version of the Perceived Stress Scale

(CPSS) was translated by Han20 and has been tested

among Chinese college students, revealing good internal

consistency reliability (α = 0.90) and test-retest reliability

(r=0.68–0.85).

Procedure
After approval from the institutional review board and

ethics committee, we put up a poster on campus for

recruitment. The modified 8-week MBSR intervention

was carried out by a qualified psychologist. The question-

naires were delivered and collected by two staff members

who were independent of our study. All students com-

pleted questionnaires at three points. The first point was

the initial baseline orientation when the MBSR interven-

tion started, the second point was the end of the 8-week

intervention, and the last point was 3 months after the

intervention.

Statistical Methods
All data analyses were performed using IBM SPSS 21.0

(version 21.0, IBM Corp., New York, NY, United States)

with bilateral inspection by two dependence assistants.

The continuous variables were assessed by means with

standard deviations or medians with ranges. Baseline

data were compared using a t-test or chi-square test

between the two groups. A repeated-measures analysis of

variance model was used to directly test the outcomes

(depression, mindfulness and rumination) between the

two groups. Statistical significance was set at p<0.05. A

p value of less than or equal to 0.05 was considered

statistically significant.

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w
it
h
m
in
d
fu
ln
e
ss

a
n
d
re
c
o
rd

y
o
u
r

fe
e
li
n
g
s.

G
iv
in
g
u
p

P
ra
c
ti
c
e
m
a
k
e
s
p
e
rf
e
c
t.

B
e
li
e
v
e
in

y
o
u
r
h
e
a
rt
.

5
-5

T
o
n
g
u
e

m
in
d
fu
ln
e
ss

1
.
T
e
a
c
h
m
e
m
b
e
rs

h
o
w

to
a
p
p
ly
m
in
d
fu
ln
e
ss

to
d
ri
n
k
in
g
a
n
d

e
a
ti
n
g
.

2
.
T
a
st
e
m
in
e
ra
l
w
a
te
r
a
n
d
a
n
a
p
p
le

w
it
h
7
st
e
p
s:
h
o
ld
,
lo
o
k
,

to
u
c
h
,
sm

e
ll
,
re
le
a
se
,
sw

a
ll
o
w

a
n
d
fe
e
l.

M
in
d
fu
ln
e
ss

e
a
ti
n
g
tr
a
in
in
g
w
it
h

ra
is
in
s.

Im
a
g
in
e
th
e
fo
o
d
so
u
rc
e
a
n
d
th
e

p
ro
c
e
ss

w
h
e
n
e
a
ti
n
g
a
n
d
re
c
o
rd

y
o
u
r

fe
e
li
n
g
s.

E
m
o
ti
o
n
a
l

in
st
a
b
il
it
y

D
o
n
o
t
ru
sh
.
S
to
p
w
h
e
n
in
a
b
a
d
st
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te
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a
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re
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k
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ri
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re
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th

to
th
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k
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a
p
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c
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l
m
in
d
.

6
-6

B
o
d
y

m
in
d
fu
ln
e
ss

1
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In
tr
o
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u
c
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h
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th
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o
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te
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p
ra
c
ti
c
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th
ro
u
g
h
th
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e
st
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m
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a
n
d

p
sy
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h
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sp
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s
to

st
re
ss

2
.
T
e
a
c
h
a
p
p
ro
p
ri
a
te

y
o
g
a
-b
a
se
d
st
re
tc
h
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s,
w
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h
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c
lu
d
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ly
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g
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p
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s.

1
.
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y
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a
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fr
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h
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to

to
e
.

2
.
A
c
c
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to

o
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rb
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d
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p
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ti
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e
b
e
fo
re

sl
e
e
p
.

(C
on
tin
ue
d)

Dovepress Zhang et al

Neuropsychiatric Disease and Treatment 2019:15
submit your manuscript | www.dovepress.com

DovePress
2699

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Powered by TCPDF (www.tcpdf.org)

Results
Sociodemographic And Clinical

Characteristics Of Participants
The average age of the participants was 18.94 ± 1.31

years, with a range of 17–22 years. Table 2 displays the

characteristics of the two groups.

Efficacy Of MBSR On BDI, MAAS, RRS
A repeated-measures analysis of variance model was con-

ducted to examine changes across time between the inter-

vention and comparison conditions on measures of BDI,

MAAS, RRS. Table 3 reveals descriptive statistics with

mean scores of pre-post measures and significance of the

group, time and time-group interactions. The results

revealed a significant interaction between time and condi-

tion for BDI (F=17.721, p<0.001, η2=0.577), MAAS
(F=13.489, p<0.001, η2=0.509), and RRS (F=81.566,
p<0.001, η2=0.863).

Discussion
This study is the first RCT pilot study to apply tailored

mindfulness-based stress reduction to mental health on

subthreshold depression college students to evaluate the

effects of MBSR on their psychological health.

Specifically, the benefits of modified MBSR on partici-

pants have been tested, such as a decrease in depression

and rumination level and an increase in mindfulness state.

Although researchers have been studying subthreshold

depression for decades, subthreshold depression is still

not recognized enough due to the lack of clear and unified

diagnostic criteria, and no authoritative academic institu-

tions have issued clear epidemiological reports.21 There

has been little research on SD in related academic fields in

China.15 Influenced by Chinese cultural values, most peo-

ple are reluctant to seek psychological counselling or

clinical psychotherapy, even if they have clinical symp-

toms that lead to an increase in the prevalence of major

depression in recent years.22 Studies have shown that the

incidence of subthreshold depression among adolescents

has reached 30~40%.23 Although subthreshold depression

does not meet the diagnosis of a clinical depressive epi-

sode, it affects the physical and mental health of indivi-

duals; thus, it is very necessary for early intervention.24

Mindfulness skills have been systematically used in

psychotherapy, and related guidelines have been recom-

mended by NICE for the treatment of depression in the

UK.25 However, for Chinese adolescents, the relatedT
a
b
le

1
(C

o
n
ti
n
u
e
d
).

W
e
e
k
-T

im
e

T
h
e
m
e
s

C
o
n
te
n
ts

H
o
m
e
w
o
rk

M
a
in

P
ro

b
le
m
s

S
o
lu
ti
o
n
s

7
-7

P
o
si
ti
v
e

th
in
k
in
g

1
.
In
tr
o
d
u
c
e
si
tt
in
g
m
e
d
it
a
ti
o
n
a
n
d
u
n
d
e
r
th
e
re
se
a
rc
h
e
rs

in
st
ru
c
ti
o
n
,
te
a
m

m
e
m
b
e
rs

h
o
w

to
p
ra
c
ti
c
e
si
tt
in
g

m
e
d
it
a
ti
o
n
.

2
.
P
u
t
fo
rw

a
rd

sp
e
c
ifi
c
e
v
e
n
ts

a
n
d
a
sk

m
e
m
b
e
rs

h
o
w
to

th
in
k

a
n
d
h
a
n
d
le

th
e
e
v
e
n
ts
.

3
.
F
in
d
o
u
t
th
e
p
ro
b
le
m
s
a
n
d
te
a
c
h
th
e
m

h
o
w

to
h
a
n
d
le

th
in
g
s
in

a
m
in
d
fu
l
w
ay
.

1
.
D
o
2
h
r
si
tt
in
g
m
e
d
it
a
ti
o
n

2
.
T
r
y
to

th
in
k
a
b
o
u
t
o
n
e
th
in
g
in

y
o
u
r
li
fe

w
it
h
m
in
d
fu
ln
e
ss