literature review on mental health

• Research article
• Open access
• Published: 24 October 2019

A scoping review of the literature on the current mental health status of physicians and physicians-in-training in North America

• Mara Mihailescu   ORCID: orcid.org/0000-0001-6878-1024 1 &
• Elena Neiterman 2  

BMC Public Health volume  19 , Article number:  1363 ( 2019 ) Cite this article

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This scoping review summarizes the existing literature regarding the mental health of physicians and physicians-in-training and explores what types of mental health concerns are discussed in the literature, what is their prevalence among physicians, what are the causes of mental health concerns in physicians, what effects mental health concerns have on physicians and their patients, what interventions can be used to address them, and what are the barriers to seeking and providing care for physicians. This review aims to improve the understanding of physicians’ mental health, identify gaps in research, and propose evidence-based solutions.

A scoping review of the literature was conducted using Arksey and O’Malley’s framework, which examined peer-reviewed articles published in English during 2008–2018 with a focus on North America. Data were summarized quantitatively and thematically.

A total of 91 articles meeting eligibility criteria were reviewed. Most of the literature was specific to burnout ( n  = 69), followed by depression and suicidal ideation ( n  = 28), psychological harm and distress ( n  = 9), wellbeing and wellness ( n  = 8), and general mental health ( n  = 3). The literature had a strong focus on interventions, but had less to say about barriers for seeking help and the effects of mental health concerns among physicians on patient care.

Conclusions

More research is needed to examine a broader variety of mental health concerns in physicians and to explore barriers to seeking care. The implication of poor physician mental health on patients should also be examined more closely. Finally, the reviewed literature lacks intersectional and longitudinal studies, as well as evaluations of interventions offered to improve mental wellbeing of physicians.

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The World Health Organization (WHO) defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” [ 41 ] One in four people worldwide are affected by mental health concerns [ 40 ]. Physicians are particularly vulnerable to experiencing mental illness due to the nature of their work, which is often stressful and characterized by shift work, irregular work hours, and a high pressure environment [ 1 , 21 , 31 ]. In North America, many physicians work in private practices with no access to formal institutional supports, which can result in higher instances of social isolation [ 13 , 27 ]. The literature on physicians’ mental health is growing, partly due to general concerns about mental wellbeing of health care workers and partly due to recognition that health care workers globally are dissatisfied with their work, which results in burnout and attrition from the workforce [ 31 , 34 ]. As a consequence, more efforts have been made globally to improve physicians’ mental health and wellness, which is known as “The Quadruple Aim.” [ 34 ] While the literature on mental health is flourishing, however, it has not been systematically summarized. This makes it challenging to identify what is being done to improve physicians’ wellbeing and which solutions are particularly promising [ 7 , 31 , 33 , 37 , 38 ]. The goal of our paper is to address this gap.

This paper explores what is known from the existing peer-reviewed literature about the mental health status of physicians and physicians-in-training in North America. Specifically, we examine (1) what types of mental health concerns among physicians are commonly discussed in the literature; (2) what are the reported causes of mental health concerns in physicians; (3) what are the effects that mental health concerns may have on physicians and their patients; (4) what solutions are proposed to improve mental health of physicians; and (5) what are the barriers to seeking and providing care to physicians with mental health concerns. Conducting this scoping review, our goal is to summarize the existing research, identifying the need for a subsequent systematic review of the literature in one or more areas under the study. We also hope to identify evidence-based interventions that can be utilized to improve physicians’ mental wellbeing and to suggest directions for future research [ 2 ]. Evidence-based interventions might have a positive impact on physicians and improve the quality of patient care they provide.

A scoping review of the academic literature on the mental health of physicians and physicians-in-training in North America was conducted using Arksey and O’Malley’s [ 2 ] methodological framework. Our review objectives and broad focus, including the general questions posed to conduct the review, lend themselves to a scoping review approach, which is suitable for the analysis of a broader range of study designs and methodologies [ 2 ]. Our goal was to map the existing research on this topic and identify knowledge gaps, without making any prior assumptions about the literature’s scope, range, and key findings [ 29 ].

Stage 1: identify the research question

Following the guidelines for scoping reviews [ 2 ], we developed a broad research question for our literature search, asking what does the academic literature tell about mental health issues among physicians, residents, and medical students in North America ? Burnout and other mental health concerns often begin in medical training and continue to worsen throughout the years of practice [ 31 ]. Recognizing that the study and practice of medicine plays a role in the emergence of mental health concerns, we focus on practicing physicians – general practitioners, specialists, and surgeons – and those who are still in training – residents and medical students. We narrowed down the focus of inquiry by asking the following sub-questions:

What types of mental health concerns among physicians are commonly discussed in the literature?

What are the reported causes of mental health problems in physicians and what solutions are available to improve the mental wellbeing of physicians?

What are the barriers to seeking and providing care to physicians suffering from mental health problems?

Stage 2: identify the relevant studies

We included in our review empirical papers published during January 2008–January 2018 in peer-reviewed journals. Our exclusive focus on peer-reviewed and empirical literature reflected our goal to develop an evidence-based platform for understanding mental health concerns in physicians. Since our focus was on prevalence of mental health concerns and promising practices available to physicians in North America, we excluded articles that were more than 10 years old, suspecting that they might be too outdated for our research interest. We also excluded papers that were not in English or outside the region of interest. Using combinations of keywords developed in consultation with a professional librarian (See Table  1 ), we searched databases PUBMed, SCOPUS, CINAHL, and PsychNET. We also screened reference lists of the papers that came up in our original search to ensure that we did not miss any relevant literature.

Stage 3: literature selection

Publications were imported into a reference manager and screened for eligibility. During initial abstract screening, 146 records were excluded for being out of scope, 75 records were excluded for being outside the region of interest, and 4 papers were excluded because they could not be retrieved. The remaining 91 papers were included into the review. Figure  1 summarizes the literature search and selection.

PRISMA Flow Diagram

Stage 4: charting the data

A literature extraction tool was created in Microsoft Excel to record the author, date of publication, location, level of training, type of article (empirical, report, commentary), and topic. Both authors coded the data inductively, first independently reading five articles and generating themes from the data, then discussing our coding and developing a coding scheme that was subsequently applied to ten more papers. We then refined and finalized the coding scheme and used it to code the rest of the data. When faced with disagreements on narrowing down the themes, we discussed our reasoning and reached consensus.

Stage 5: collating, summarizing, and reporting the results

The data was summarized by frequency and type of publication, mental health topics, and level of training. The themes inductively derived from the data included (1) description of mental health concerns affecting physicians and physicians-in-training; (2) prevalence of mental health concerns among this population; (3) possible causes that can explain the emergence of mental health concerns; (4) solutions or interventions proposed to address mental health concerns; (5) effects of mental health concerns on physicians and on patient outcomes; and (6) barriers for seeking and providing help to physicians afflicted with mental health concerns. Each paper was coded based on its relevance to major theme(s) and, if warranted, secondary focus. Therefore, one paper could have been coded in more than one category. Upon analysis, we identified the gaps in the literature.

Characteristics of included literature

The initial search yielded 316 records of which 91 publications underwent full-text review and were included in our scoping review. Our analysis revealed that the publications appear to follow a trend of increase over the course of the last decade reflecting the growing interest in physicians’ mental health. More than half of the literature was published in the last 4 years included in the review, from 2014 to 2018 ( n  = 55), with most publications in 2016 ( n  = 18) (Fig.  2 ). The majority of papers ( n  = 36) focused on practicing physicians, followed by papers on residents ( n  = 22), medical students ( n  = 21), and those discussing medical professionals with different level of training ( n  = 12). The types of publications were mostly empirical ( n  = 71), of which 46 papers were quantitative. Furthermore, the vast majority of papers focused on the United States of America (USA) ( n  = 83), with less than 9% focusing on Canada ( n  = 8). The frequency of identified themes in the literature is broken down into prevalence of mental health concerns ( n  = 15), causes of mental health concerns ( n  = 18), effects of mental health concerns on physicians and patients ( n  = 12), solutions and interventions for mental health concerns ( n  = 46), and barriers to seeking and providing care for mental health concerns ( n  = 4) (Fig.  3 ).

Number of sources by characteristics of included literature

Frequency of themes in literature ( n  = 91)

Mental health concerns and their prevalence in the literature

In this thematic category ( n  = 15), we coded the papers discussing the prevalence of specific mental health concerns among physicians and those comparing physicians’ mental health to that of the general population. Most papers focused on burnout and stress ( n  = 69), which was followed by depression and suicidal ideation ( n  = 28), psychological harm and distress ( n  = 9), wellbeing and wellness ( n  = 8), and general mental health ( n  = 3) (Fig.  4 ). The literature also identified that, on average, burnout and mental health concerns affect 30–60% of all physicians and residents [ 4 , 5 , 8 , 9 , 15 , 25 , 26 ].

Number of sources by mental health topic discussed ( n  = 91)

There was some overlap between the papers discussing burnout, depression, and suicidal ideation, suggesting that work-related stress may lead to the emergence of more serious mental health problems [ 3 , 12 , 21 ], as well as addiction and substance abuse [ 22 , 27 ]. Residency training was shown to produce the highest rates of burnout [ 4 , 8 , 19 ].

Causes of mental health concerns

Papers discussing the causes of mental health concerns in physicians formed the second largest thematic category ( n  = 18). Unbalanced schedules and increasing administrative work were defined as key factors in producing poor mental health among physicians [ 4 , 5 , 6 , 13 , 15 , 27 ]. Some papers also suggested that the nature of the medical profession itself – competitive culture and prioritizing others – can lead to the emergence of mental health concerns [ 23 , 27 ]. Indeed, focus on qualities such as rigidity, perfectionism, and excessive devotion to work during the admission into medical programs fosters the selection of students who may be particularly vulnerable to mental illness in the future [ 21 , 24 ]. The third cluster of factors affecting mental health stemmed from structural issues, such as pressure from the government and insurance, fragmentation of care, and budget cuts [ 13 , 15 , 18 ]. Work overload, lack of control over work environment, lack of balance between effort and reward, poor sense of community among staff, lack of fairness and transparency by decision makers, and dissonance between one’s personal values and work tasks are the key causes for mental health concerns among physicians [ 20 ]. Govardhan et al. conceptualized causes for mental illness as having a cyclical nature - depression leads to burnout and depersonalization, which leads to patient dissatisfaction, causing job dissatisfaction and more depression [ 19 ].

Effects of mental health concerns on physicians and patients

A relatively small proportion of papers (13%) discussed the effects of mental health concerns on physicians and patients. The literature prioritized the direct effect of mental health on physicians ( n  = 11) with only one paper focusing solely on the indirect effects physicians’ mental health may have on patients. Poor mental health in physicians was linked to decreased mental and physical health [ 3 , 14 , 15 ]. In addition, mental health concerns in physicians were associated with reduction in work hours and the number of patients seen, decrease in job satisfaction, early retirement, and problems in personal life [ 3 , 5 , 15 ]. Lu et al. found that poor mental health in physicians may result in increased medical errors and the provision of suboptimal care [ 25 ]. Thus physicians’ mental wellbeing is linked to the quality of care provided to patients [ 3 , 4 , 5 , 10 , 17 ].

Solutions and interventions

In this largest thematic category ( n  = 46) we coded the literature that offered solutions for improving mental health among physicians. We identified four major levels of interventions suggested in the literature. A sizeable proportion of literature discussed the interventions that can be broadly categorized as primary prevention of mental illness. These papers proposed to increase awareness of physicians’ mental health and to develop strategies that can help to prevent burnout from occurring in the first place [ 4 , 12 ]. Some literature also suggested programs that can help to increase resilience among physicians to withstand stress and burnout [ 9 , 20 , 27 ]. We considered the papers referring to the strategies targeting physicians currently suffering from poor mental health as tertiary prevention . This literature offered insights about mindfulness-based training and similar wellness programs that can increase self-awareness [ 16 , 18 , 27 ], as well as programs aiming to improve mental wellbeing by focusing on physical health [ 17 ].

While the aforementioned interventions target individual physicians, some literature proposed workplace/institutional interventions with primary focus on changing workplace policies and organizational culture [ 4 , 13 , 23 , 25 ]. Reducing hours spent at work and paperwork demands or developing guidelines for how long each patient is seen have been identified by some researchers as useful strategies for improving mental health [ 6 , 11 , 17 ]. Offering access to mental health services outside of one’s place of employment or training could reduce the fear of stigmatization at the workplace [ 5 , 12 ]. The proposals for cultural shift in medicine were mainly focused on promoting a less competitive culture, changing power dynamics between physicians and physicians-in-training, and improving wellbeing among medical students and residents. The literature also proposed that the medical profession needs to put more emphasis on supporting trainees, eliminating harassment, and building strong leadership [ 23 ]. Changing curriculum for medical students was considered a necessary step for the cultural shift [ 20 ]. Finally, while we only reviewed one paper that directly dealt with the governmental level of prevention, we felt that it necessitated its own sub-thematic category because it identified the link between government policy, such as health care reforms and budget cuts, and the services and care physicians can provide to their patients [ 13 ].

Barriers to seeking and providing care

Only four papers were summarized in this thematic category that explored what the literature says about barriers for seeking and providing care for physicians suffering from mental health concerns. Based on our analysis, we identified two levels of factors that can impact access to mental health care among physicians and physicians-in-training.

Individual level barriers stem from intrinsic barriers that individual physicians may experience, such as minimizing the illness [ 21 ], refusing to seek help or take part in wellness programs [ 14 ], and promoting the culture of stoicism [ 27 ] among physicians. Another barrier is stigma associated with having a mental illness. Although stigma might be experienced personally, literature suggests that acknowledging the existence of mental health concerns may have negative consequences for physicians, including loss of medical license, hospital privileges, or professional advancement [ 10 , 21 , 27 ].

Structural barriers refer to the lack of formal support for mental wellbeing [ 3 ], poor access to counselling [ 6 ], lack of promotion of available wellness programs [ 10 ], and cost of treatment. Lack of research that tests the efficacy of programs and interventions aiming to improve mental health of physicians makes it challenging to develop evidence-based programs that can be implemented at a wider scale [ 5 , 11 , 12 , 18 , 20 ].

Our analysis of the existing literature on mental health concerns in physicians and physicians-in-training in North America generated five thematic categories. Over half of the reviewed papers focused on proposing solutions, but only a few described programs that were empirically tested and proven to work. Less common were papers discussing causes for deterioration of mental health in physicians (20%) and prevalence of mental illness (16%). The literature on the effects of mental health concerns on physicians and patients (13%) focused predominantly on physicians with only a few linking physicians’ poor mental health to medical errors and decreased patient satisfaction [ 3 , 4 , 16 , 24 ]. We found that the focus on barriers for seeking and receiving help for mental health concerns (4%) was least prevalent. The topic of burnout dominated the literature (76%). It seems that the nature of physicians’ work fosters the environment that causes poor mental health [ 1 , 21 , 31 ].

While emphasis on burnout is certainly warranted, it might take away the attention paid to other mental health concerns that carry more stigma, such as depression or anxiety. Establishing a more explicit focus on other mental health concerns might promote awareness of these problems in physicians and reduce the fear such diagnosis may have for doctors’ job security [ 10 ]. On the other hand, utilizing the popularity and non-stigmatizing image of “burnout” might be instrumental in developing interventions promoting mental wellbeing among a broad range of physicians and physicians-in-training.

Table  2 summarizes the key findings from the reviewed literature that are important for our understanding of physician mental health. In order to explicitly summarize the gaps in the literature, we mapped them alongside the areas that have been relatively well studied. We found that although non-empirical papers discussed physicians’ mental wellbeing broadly, most empirical papers focused on medical specialty (e.g. neurosurgeons, family medicine, etc.) [ 4 , 8 , 15 , 19 , 25 , 28 , 35 , 36 ]. Exclusive focus on professional specialty is justified if it features a unique context for generation of mental health concerns, but it limits the ability to generalize the findings to a broader population of physicians. Also, while some papers examined the impact of gender on mental health [ 7 , 32 , 39 ], only one paper considered ethnicity as a potential factor for mental health concerns and found no association [ 4 ]. Given that mental health in the general population varies by gender, ethnicity, age, and sexual orientation, it would be prudent to examine mental health among physicians using an intersectional analysis [ 30 , 32 , 39 ]. Finally, of the empirical studies we reviewed, all but one had a cross-sectional design. Longitudinal design might offer a better understanding of the emergence and development of mental health concerns in physicians and tailor interventions to different stages of professional career. Additionally, it could provide an opportunity to evaluate programs’ and policies’ effectiveness in improving physicians’ mental health. This would also help to address the gap that we identified in the literature – an overarching focus on proposing solutions with little demonstrated evidence they actually work.

This review has several limitations. First, our focus on academic literature may have resulted in overlooking the papers that are not peer-reviewed but may provide interesting solutions to physician mental health concerns. It is possible that grey literature – reports and analyses published by government and professional organizations – offers possible solutions that we did not include in our analysis or offers a different view on physicians’ mental health. Additionally, older papers and papers not published in English may have information or interesting solutions that we did not include in our review. Second, although our findings suggest that the theme of burnout dominated the literature, this may be the result of the search criteria we employed. Third, following the scoping review methodology [ 2 ], we did not assess the quality of the papers, focusing instead on the overview of the literature. Finally, our research was restricted to North America, specifically Canada and the USA. We excluded Mexico because we believed that compared to the context of medical practice in Canada and the USA, which have some similarities, the work experiences of Mexican physicians might be different and the proposed solutions might not be readily applicable to the context of practice in Canada and the USA. However, it is important to note that differences in organization of medical practice in Canada and the USA do exist, as do differences across and within provinces in Canada and the USA. A comparative analysis can shed light on how the structure and organization of medical practice shapes the emergence of mental health concerns.

The scoping review we conducted contributes to the existing research on mental wellbeing of American and Canadian physicians by summarizing key knowledge areas and identifying key gaps and directions for future research. While the papers reviewed in our analysis focused on North America, we believe that they might be applicable to the global medical workforce. Identifying key gaps in our knowledge, we are calling for further research on these topics, including examination of medical training curricula and its impact on mental wellbeing of medical students and residents, research on common mental health concerns such as depression or anxiety, studies utilizing intersectional and longitudinal approaches, and program evaluations assessing the effectiveness of interventions aiming to improve mental wellbeing of physicians. Focus on the effect physicians’ mental health may have on the quality of care provided to patients might facilitate support from government and policy makers. We believe that large-scale interventions that are proven to work effectively can utilize an upstream approach for improving the mental health of physicians and physicians-in-training.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

United States of America

World Health Organization

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M.M. and E.N. were involved in identifying the relevant research question and developing the combinations of keywords used in consultation with a professional librarian. M.M. performed the literature selection and screening of references for eligibility. Both authors were involved in the creation of the literature extraction tool in Excel. Both authors coded the data inductively, first independently reading five articles and generating themes from the data, then discussing their coding and developing a coding scheme that was subsequently applied to ten more papers. Both authors then refined and finalized the coding scheme and M.M. used it to code the rest of the data. M.M. conceptualized and wrote the first copy of the manuscript, followed by extensive drafting by both authors. E.N. was a contributor to writing the final manuscript. All authors read and approved the final manuscript.

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Mihailescu, M., Neiterman, E. A scoping review of the literature on the current mental health status of physicians and physicians-in-training in North America. BMC Public Health 19 , 1363 (2019). https://doi.org/10.1186/s12889-019-7661-9

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Examining the mental health services among people with mental disorders: a literature review

• Yunqi Gao 1 ,
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• Miranda R. Chilver 1 &
• Peter Butterworth 2 , 3  

BMC Psychiatry volume  24 , Article number:  568 ( 2024 ) Cite this article

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Mental disorders are a significant contributor to disease burden. However, there is a large treatment gap for common mental disorders worldwide. This systematic review summarizes the factors associated with mental health service use.

PubMed, Scopus, and the Web of Science were searched for articles describing the predictors of and barriers to mental health service use among people with mental disorders from January 2012 to August 2023. The initial search yielded 3230 articles, 2366 remained after removing duplicates, and 237 studies remained after the title and abstract screening. In total, 40 studies met the inclusion and exclusion criteria.

Middle-aged participants, females, Caucasian ethnicity, and higher household income were more likely to access mental health services. The use of services was also associated with the severity of mental symptoms. The association between employment, marital status, and mental health services was inconclusive due to limited studies. High financial costs, lack of transportation, and scarcity of mental health services were structural factors found to be associated with lower rates of mental health service use. Attitudinal barriers, mental health stigma, and cultural beliefs also contributed to the lower rates of mental health service use.

This systematic review found that several socio-demographic characteristics were strongly associated with using mental health services. Policymakers and those providing mental health services can use this information to better understand and respond to inequalities in mental health service use and improve access to mental health treatment.

Peer Review reports

Introduction

Mental disorders such as depression and anxiety are prevalent, with nationally representative studies showing that one-fifth of Australians experience a mental disorder each year [ 5 ]. More recent estimates derived from a similar survey during the period of the COVID-19 pandemic were 21.5% [ 11 ]. Mental illness can reduce the quality of life, and increase the likelihood of communicable and non-communicable diseases [ 116 , 137 ], and is among the costliest burdens in developed countries [ 22 , 34 , 80 ]. The National Mental Health Commission [ 96 ] stated that the annual cost of mental ill-health in Australia was around $4000 per person or $60 billion. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 reported that mental disorders rank the seventh leading cause of disability-adjusted life years and the second leading cause of years lived with disability [ 48 ]. Helliwell et al. [ 56 ] indicated that chronic mental illness was a key determinant of unhappiness, and it triggered more pain than physical illness. Mental health issues can have a spillover effect on all areas of life, poor mental health conditions might lead to lower educational achievements and work performance, substance abuse, and violence [ 102 ]. In Australia, despite considerable additional investment in the provision of mental health services research suggests that the rate of psychological distress at the population level has been increasing [ 38 ], this has been argued to reflect that people who most need mental health treatment are not accessing services. Insufficient numbers of mental health services and mental healthcare professionals and inadequate health literacy have been reported as the pivotal determinants of poor mental health [ 18 ]. Previous studies have reported large treatment gaps in mental health services; finding only 42–44% of individuals with mental illness seek help from any medical or professional service provider [ 85 , 112 ] and this active proportion was much lower in low and middle-income countries [ 32 , 114 , 130 ].

Several studies have investigated factors associated with high and low rates of mental health service use and identified potential barriers to accessing mental health service use. Demographic, social, and structural factors have been associated with low rates of mental health service use. Structural barriers include the availability of mental health services and high treatment costs, social barriers to treatment access include stigma around mental health [ 125 ], fear of being perceived as weak or stigmatized [ 79 ], lack of awareness of mental disorders, and cultural stigma [ 17 ].

Existing studies that have systematically reviewed and evaluated the literature examining mental health service use have largely been constrained to specific population groups such as military service members [ 63 ] and immigrants [ 33 ], children and adolescents [ 35 ], young adults [ 76 ], and help-seeking among Filipinos in the Philippines [ 93 ]. These systematic reviews emphasize mental health service use by specific age groups or sub-groups, and the findings might not represent the patterns and barriers to mental health service use in the general population. One paper has reviewed mental health service use in the general adult population. Roberts et al. [ 112 ] found that need factors (e.g. health status, disability, duration of symptoms) were the strongest determinants of health service use for those with mental disorders.

The study results from Roberts et al. [ 112 ] were retrieved in 2016, and the current study seeks to build on this prior review with more recent research data by identifying publications since 2012 on mental health service use with a focus on high-income countries. This is in the context of ongoing community discussion and reform of the design and delivery of mental health services in Australia [ 140 ], and the need for current evidence to inform this discussion in Australia and other high-income countries. This systematic review aims to investigate factors associated with mental health service use among people with mental disorders and summarize the major barriers to mental health treatment. The specific objectives are (1) to identify factors associated with mental health service use among people with mental disorders in high-income countries, and (2) to identify commonly reported barriers to mental health service use.

Methodology

Selection procedures.

Our review adhered to PRISMA guidelines to present the results. We utilized PubMed, Scopus, and the Web of Science to search for articles describing the facilitators and barriers to mental health service use among people with mental illness from January 2012 up to August 2023. There were no specific factors that were of interest as part of conducting this systematic review, instead, the review had a broad focus intending to identify factors shown to be associated with mental health service use in the recent literature. The keywords used in our search of electronic databases were related to mental disorders and mental health service use. The full search terms and strategies were shown in Supplementary Table 1. We uploaded the search results to Covidence for deduplication and screening. After eliminating duplicates, the first author retrieved the title abstract and full-text articles for all eligible papers. Then each title and abstract were screened by two independent reviewers, to select those that would progress to full-text review. Subsequently, the two reviewers screened the full text of all the selected papers and conducted the data extraction for those that met the eligibility criteria. There were discrepancies in 12% of the papers reviewed, and all conflicts were resolved through discussion and agreed on by at least three authors.

Selection criteria

Inclusion and exclusion criteria.

In this systematic review, the scope was restricted to studies that draw samples from the general population, and the participants were either diagnosed with mental disorders or screened positive using a standardized scale. Case-control studies and cohort studies were considered for inclusion. The applied inclusion and exclusion criteria are listed in Table 1 .

Data extraction

After the full-text screening, details from all eligible studies were extracted by field into a data extraction table with thematic headings. The descriptive data includes the study title, author, publication year, geographic location, sample size, population details (gender, age), type of study design, mental disorder type (medical diagnosis or using scales) and quality grade (e.g. good, fair, and poor).

Quality assessment

The Newcastle Ottawa Scale [ 136 ] was used to evaluate the study quality for all eligible papers. We assessed the cross-sectional and cohort studies using separate assessment forms and graded each study as good, fair, or poor. The quality grade for each study was included in the data extraction table. The first author conducted the quality assessment using the Newcastle Ottawa Scale for cohort studies and the adapted scale for cross-sectional studies.

The search process is summarized in Fig. 1 . The initial search from PubMed, Scopus, and the Web of Science yielded 3230 articles: 2366 remained after removing duplicates; 2129 studies were considered not relevant; and 237 studies remained following title and abstract screening. In total, 40 studies met the inclusion criteria. Of these, four were cohort studies while thirty-six were cross-sectional studies. Ten studies (25.0%) were conducted in Canada, and nine (22.5%) were from the United States. Three studies used data from Germany (7.5%). Two studies each reported data from Australia, Denmark, Sweden, Singapore, or South Korea (5.0% of studies for each country). A single study was included with data from either the United Kingdom, Italy, Israel, Portugal, Switzerland, Chile, New Zealand, or reported pooled multinational data from six European countries (each country/ study representing 2.5% of the total sample of studies) (Table 2 ).

Flowchart for selections of studies

Study characteristics

As shown in Tables 2 ,  3 and 4 , the sample size of studies varies; a cross-sectional study from Canada had the largest sample which contained over seven million participants [ 39 ], while the smallest sample size was 362 [ 100 ]. Sixteen studies (40.0%) used DSM-IV diagnoses [ 4 ] to measure mental disorders, twelve studies (30.0%) applied the International Classification of Disease [ 138 ], and six studies used (15.0%) the Kessler Psychological Distress Scale [ 69 ]. Only three studies (7.5%) had a hospital diagnosis of mental disorders, while three studies (7.5%) used the Patient Health Questionnaire [ 72 ] to define mental disorders.

Twenty-seven studies (67.5%) analyzed the rate of mental health service use over the last 12 months, six studies (15.0%) focused on lifetime service use, and three studies (7.5%) assessed both 12-month and lifetime mental health service use. A few studies examined other time frames, with single studies investigating mental health service use over the past 3 months, 5 years, and 7 years, and one included study considered mental health service use during the 24 months before and after a sibling’s death.

Twenty of the forty studies were classified as good quality (50.0%), seventeen as fair (42.5%), and three as poor quality (7.5%).

Overview of samples and factors investigated

The included studies examined a range of different factors associated with mental health service use. These included gender, age, marital status, ethnic groups, alcohol and drug abuse, education and income level, employment status, symptom severity, and residential location. The review identified service utilization factors related to socio-demographics, differences in utilization across countries, emerging socio-demographic factors and contexts, as well as structural and attitudinal barriers. These are described in further detail below.

Socio-demographic characteristics

Fifteen studies analyzed the association between gender and mental health service use, with fourteen studies reporting that mental health service use was more frequent among females with mental disorders than males [ 2 , 37 , 42 , 43 , 47 , 54 , 66 , 67 , 90 , 103 , 119 , 123 , 128 , 130 ]. A South Korean study concluded that gender was not associated with mental health service use [ 100 ], which might be due to the small sample size of 362 participants in the study.

Fourteen studies investigated age in association with mental health service use. Nine studies concluded that mental health service use was lower among young and old adult groups, with middle-aged persons with a mental disorder being most likely to access treatment from a mental health professional [ 26 , 42 , 43 , 47 , 54 , 66 , 67 , 123 , 130 ]. Forslund et al. [ 43 ] reported that mental health service use for women in Sweden peaked in the 45-to-64-year age group, while amongst males, mental health service use was stable across the lifespan. In contrast, two articles from New Zealand and Singapore each reported that young adults were the age group most likely to access services [ 28 , 119 ]. Reich et al. [ 103 ] concluded that age was unrelated to mental health service use when considered for the whole population, but sex-specific analyses reported that mental health service use was higher in older than younger females, while the opposite pattern was observed for males. A Canadian study using community health survey data also observed no significant age-related differences in mental health service use [ 104 ].

Marital status

There was mixed evidence concerning marital status. Studies from the United States and Germany concluded that participants who were married or cohabiting had lower rates of mental health service use [ 26 , 90 ], while Silvia et al. [ 120 ] found that mental health service use was higher among married participants in Portugal. Shafie et al. [ 119 ] reported being widowed was associated with lower rates of mental health service use in Singapore.

Ethnic groups

Eight studies examined the relationship between ethnic background and mental healthcare service use. Non-Hispanic White respondents were more likely to use mental health services in Canada and the United States [ 24 , 26 , 30 , 130 , 139 ], while Asians showed lower rates of mental health service use [ 28 , 139 ]. Chow & Mulder [ 28 ] investigated mental health service use among Asians, Europeans, Maori, and Pacific peoples in New Zealand. They concluded that Maori had the highest rate of mental health service use compared with other ethnic groups. De Luca et al. [ 30 ] reported that mental health service use was lower among ethnic minority non-veterans compared to veterans in the United States, especially for those with Black or Hispanic backgrounds. In contrast, a study conducted in the UK found that mental health service use did not vary by ethnicity, with no difference between white and non-white persons [ 54 ].

Alcohol and drug abuse

Two studies reported risky alcohol use was negatively associated with mental health service use [ 26 , 132 ]. However, within the time frame of the current review, there was insufficient published evidence on the impact of drug abuse on mental health service use among people with mental disorders. Choi, Diana & Nathan [ 26 ] found that drug abuse can lead to lower rates of mental health service use in the United States. In contrast, Werlen et al. [ 132 ] reported that risky use of (non-prescribed) prescription medications was associated with higher rates of mental health service use in Switzerland.

Education, income, and employment status

Four studies analyzed the relationship between education level, income, and mental health service use. Higher levels of educational attainment [ 26 , 120 ] and higher income [ 26 ] were generally reported to be associated with an increased likelihood of mental health service use. However, Reich et al. [ 103 ] observed that in Germany, high education and perceived middle or high social class were associated with reduced mental health service use. One paper reported no significant difference in mental health service use in South Korea, possibly due to the small number of people accessing mental healthcare services [ 100 ].

Three studies reported that compared to those who are unemployed, those in work were less likely to use mental health services [ 26 , 90 , 119 ]. This outcome aligned with a Canadian study consisting of immigrants and general populations, Islam et al. [ 66 ] concluded that immigrants who were currently unemployed had higher odds of seeking treatment than those who were employed. However, an Italian [ 123 ] and a South Korean study [ 100 ] found that employment status was not related to mental health service use.

Symptom severity

Ten studies investigated the association between symptom severity and mental health service use and ten papers concluded that participants with moderate or serious psychological symptoms were more likely to use mental health services compared to those with mild symptoms [ 23 , 27 , 66 , 103 , 120 , 123 , 130 , 139 ]. Other studies showed that study participants who viewed their mental health as poor [ 42 ], who were diagnosed with more than one mental disorder [ 103 ], and those who recognized their own need for mental health treatment [ 54 , 139 ] were more likely to receive mental health services.

Residential location

Three studies investigated the association between residential location and mental health service use. Volkert et al. [ 128 ] concluded that the rates of mental health service use in Germany were significantly lower among those living in Canterbury than those living in Hamburg. A Canadian study found individuals living in neighborhoods where renters outnumber homeowners were less likely to access mental health services [ 42 ]. In the United States, for participants with low or moderate mental illness, mental health service use was lower for those residing closer to clinics [ 46 ].

Immigrants & refugees

The reviewed research found that non-refugee immigrants had slightly higher rates of mental health service use than refugees [ 10 ]. Other research found that long-term residents were more likely to access services than immigrants regardless of their origin [ 31 , 134 ]. For example, Italian citizens were found to have higher rates of mental health service use compared to immigrants, especially for affective disorders [ 123 ]. In Canada, immigrants from West and Central Africa were more likely to access mental health services compared to immigrants from East Asia and the Pacific [ 31 ]. Research from Chile found that the rates of mental health service use were similar for immigrants and non-immigrants [ 40 ]. Although, a positive association between the severity of symptoms and rates of mental health service use was only observed among immigrants [ 40 ]. Whitley et al. [ 134 ] found that immigrants born in Asia or Africa had lower rates of mental health service use, but higher rates of service satisfaction scores compared to immigrants from other countries.

Emerging areas

Our literature review identified several areas in which only a small number of studies were found. We briefly describe them here as these may reflect emerging areas of research interest. Few published articles examined mental health treatment among participants with mental disorders together with chronic physical health conditions, and we only included the papers in this systematic review if they contained a healthy comparison group. We identified two papers that focused on survivors of adolescent and young adult cancer [ 68 ] and participants with physical health problems [ 110 ]. Both studies reported that participants with other chronic conditions reported higher rates of mental health service use than the general population [ 68 , 110 ].

Two studies compared treatment seeking among people experiencing stressful life events. Erlangsen et al. [ 39 ] investigated the impact of spousal suicide, and Gazibara et al. [ 45 ] examined the effect of a sibling’s death on mental health service use. People bereaved by relatives’ deaths were more likely to use mental health services than the general population [ 39 , 45 ]. The peak effect was observed in the first 3 months after the death for both genders, while evidence of an increase in mental health service use was evident up to 24 months before a sibling’s death and remained evident for at least 24 months after the death [ 45 ].

One paper studied the impact of the COVID-19 pandemic lockdown on mental health service use. An Israeli study concluded that compared to 2018 and 2019, adults reported they were reluctant to receive treatment during the pandemic lockdown and observed a decrease in mental health service use [ 13 ].

Structural and attitudinal barriers

In addition to the research considering a range of population characteristics (e.g. male, younger, or older age), several papers examined how attitudinal and structural factors were associated with mental health service use. The most frequently reported of these factors were cost [ 23 , 46 , 68 , 120 ], lack of transportation [ 46 , 83 ], inadequate services/ lack of availability [ 23 , 46 , 83 , 128 ], poor understanding of mental disorders and what services were available [ 10 , 11 , 22 , 83 , 100 , 105 , 120 ], language difficulties [ 10 ], and stigma-related barriers [ 83 , 100 , 103 , 105 , 128 ]. Cultural issues and personal beliefs may influence the understanding of mental disorders and prevent people from using mental health services due to mistrust or fear of treatment [ 100 , 128 ]. The review also observed some unique barriers to different population groups. Choi, Diana & Nathan [ 26 ] mentioned that lack of readiness and treatment cost were the biggest difficulties for older adults, while young participants were more concerned about stigma. Females also reported childcare as a factor limiting their ability to use mental health services, while the evidence reviewed argued that males prefer to solve mental health issues on their own, with internal control beliefs and lack of social support likely reducing their use of mental health services [ 37 , 103 ].

Summary of evidence

This systematic review investigated mental health service use among people with mental disorders and identified the factors associated with service use in high-income countries.

Most studies found that females with mental health conditions were more likely to use mental health services than males. The relationship between age and mental health service use was bell-shaped, with middle-aged participants having higher rates of mental health service use than other age groups. Possible explanations included that the elderly might be reluctant to disclose mental health symptoms, they might attribute their mental health symptoms to increasing age [ 20 ], and they may prefer to self-manage instead of seeking help from health professionals [ 44 ]. Caucasian ethnicity and higher household income were also associated with higher rates of mental health service use. Greater use of mental health services was observed in participants with severe mental symptoms, including among veterans [ 19 , 37 , 92 ]. Two studies also concluded that compared to other cultural groups, Asian respondents were more likely to receive treatment when problems were severe or had disabling effects [ 86 , 97 ]. There was mixed evidence regarding employment status, although some studies found employment to be negatively related to receiving treatment [ 26 , 90 ], and unemployed people are more likely to seek help [ 119 ]. There was inconsistent evidence for the association between marital status and service utilization. This contradictory evidence on marital status might be attributed to a lack of specification, some papers categorize it as married and non-married [ 26 , 71 , 131 ], while others further differentiate between those who were widowed, separated, and divorced [ 90 , 119 ].

A number of studies showed that immigrants can face unique stressors owing to their experience of migration, which may exacerbate or be the source of their mental health issues, and impact the use of mental health services [ 1 , 8 ]. These include separation from families, support networks, linguistic and cultural barriers [ 9 , 113 ].

Due to the increased number of international migrants, immigrants’ mental health status and healthcare use has drawn growing attention [ 7 , 77 , 99 ]. Kirmayer et al. [ 70 ] and Helman [ 57 ] found that culture might be associated with people’s attitudes and understanding of mental health, influencing help-seeking behaviors. In general, the current results showed that immigrants and refugees were less likely to use mental health services than their native-born counterparts, and this finding was consistent with previous studies [ 75 , 82 , 127 ]. For immigrants, the length of stay in the host country was closely related to rates of mental health service use, which was argued to reflect increasing familiarity with the host culture and language proficiency [ 1 , 59 ].

Both mental disorders and chronic diseases contribute significantly to the global burden of disease. Prior studies have shown that people with chronic disease have a higher chance of experiencing psychological distress [ 6 , 14 , 68 , 73 ], and vice versa [ 49 , 74 ]. Hendrie et al. [ 58 ] concluded that respondents with chronic diseases were more likely to attend mental healthcare and reported higher costs. Negative experiences and stressful consequences related to chronic disease might contribute to the increased potential for mental illness but more opportunities to seek help from health professionals [ 60 , 108 , 135 ]. People with chronic diseases and mental health problems might experience more long-term pain and limitations in their daily lives, and these stressors can exacerbate their health conditions, and impact their attitude toward seeking help.

The COVID-19 pandemic had a major impact on mental health service use worldwide, the hospital admission and consultation rate decreased dramatically during the first pandemic year [ 118 ]. This reduction in service access might be a side effect of social distancing measures taken as mitigation measures, reducing both inciting incidents and physical access to services.

Financial difficulty, service availability, and stigma were frequently identified in the literature as structural and attitudinal factors associated with lower rates of mental health service use. These factors were associated with the different rates of mental health service use for different ethnicities. For example, Asian people were less likely than other groups to identify cost as a factor limiting their use of mental health services, with a major barrier for Asian people being stigma and cultural factors [ 139 ].

Limitations

This systematic review employed a broad search strategy with broad search terms to capture relevant articles. Rather than emphasizing a particular mental disorder, this review focused on the rates of mental health service use among adults aged 18 years or older who were experiencing a common mental disorder. However, this review still contained limitations. First was the potential for selection bias. Although we used various search terms for mental health service use and mental disorder, it is possible that the service use was not the primary research question for some papers, or that the relevant service use outcome was not statistically significant- in these cases, if the information was not reported in the abstract, relevant papers might have been missed. It is also important to note that this systematic review includes studies conducted in different countries and that the mental health systems and opportunities for access vary among countries. We only searched for full-text peer-reviewed articles published in English. Grey literature and papers published in other languages were excluded from the search. Most of the included literature used self-reported data to measure service access, and these data can be liable to recall bias. Studies using administrative data were also included in the systematic review, and we note that although they have large datasets, compared to survey data, there is often a lack of adequate control variables included to minimize possible confounding influences.

Future research

There is a need for more published articles on several aspects that may influence the service utilization among people with mental disorders, including the impact of residential or neighborhood areas, and household income across various income groups. These aspects are important population characteristics that require further research to inform the targeting and type of support (e.g. low-cost, accessible). Additionally, there was a lack of longitudinal research on mental health service use, future studies could use the data to identify changes over time and relate events to specific exposures (e.g. Covid-19 pandemic). Future studies can investigate the cost of mental health treatment in detailed aspects, (e.g. publicly funded mental health services, community-based support for free or low-cost mental health services). Overall, there was a lack of studies for ethnic minorities, given ethnic minority groups were more vulnerable to mental disorders but with less mental health service use. Future research can expand gender identity representation in data collection and move beyond the binary genders. People with non-binary gender identities can face greater challenges and disadvantages in mental health and mental health service use.

This review identified that middle-aged, female gender, Caucasian ethnicity, and severity of mental disorder symptoms were factors consistently associated with higher rates of mental health service use among people with a mental disorder. In comparison, the influence of employment and marital status on mental health service use was unclear due to the limited number of published studies and/ or mixed results. Financial difficulty, stigma, lack of transportation, and inadequate mental health services were the structural barriers most consistently identified as being associated with lower rates of mental health service use. Finally, ethnicity and immigrant status were also associated with differences in understanding of mental health (i.e. mental health literacy), effectiveness of mental health treatments, as well as language difficulties. The insights gained through this review on the factors associated with mental health service use can help clinicians and policymakers to identify and provide more targeted support for those least likely to access services, and this in turn may contribute to reducing inequalities in not only mental health service use but also the burden of mental disorders.

Availability of data and materials

All data and materials related to the study are available on request from the first author, [email protected].

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Yunqi Gao, Richard Burns, Liana Leach & Miranda R. Chilver

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Mindfulness-based interventions: an overall review

Dexing zhang, eric k p lee, eva c w mak, samuel y s wong.

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Received 2020 Aug 16; Revised 2020 Dec 27; Accepted 2021 Feb 2.

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Introduction

This is an overall review on mindfulness-based interventions (MBIs).

Sources of data

We identified studies in PubMed, EMBASE, CINAHL, PsycINFO, AMED, Web of Science and Google Scholar using keywords including ‘mindfulness’, ‘meditation’, and ‘review’, ‘meta-analysis’ or their variations.

Areas of agreement

MBIs are effective for improving many biopsychosocial conditions, including depression, anxiety, stress, insomnia, addiction, psychosis, pain, hypertension, weight control, cancer-related symptoms and prosocial behaviours. It is found to be beneficial in the healthcare settings, in schools and workplace but further research is warranted to look into its efficacy on different problems. MBIs are relatively safe, but ethical aspects should be considered. Mechanisms are suggested in both empirical and neurophysiological findings. Cost-effectiveness is found in treating some health conditions.

Areas of controversy

Inconclusive or only preliminary evidence on the effects of MBIs on PTSD, ADHD, ASD, eating disorders, loneliness and physical symptoms of cardiovascular diseases, diabetes, and respiratory conditions. Furthermore, some beneficial effects are not confirmed in subgroup populations. Cost-effectiveness is yet to confirm for many health conditions and populations.

Growing points

Many mindfulness systematic reviews and meta-analyses indicate low quality of included studies, hence high-quality studies with adequate sample size and longer follow-up period are needed.

Areas timely for developing research

More research is needed on online mindfulness trainings and interventions to improve biopsychosocial health during the COVID-19 pandemic; Deeper understanding of the mechanisms of MBIs integrating both empirical and neurophysiological findings; Long-term compliance and effects of MBIs; and development of mindfulness plus (mindfulness+) or personalized mindfulness programs to elevate the effectiveness for different purposes.

Keywords: mindfulness-based interventions, biopsychosocial health, safety, ethics, compliance, mechanisms

Mindfulness and mindfulness-based interventions

Mindfulness is a moment-by-moment awareness of thoughts, feelings, bodily sensations and surrounding environment. Being mindful is related to be open, nonjudgmental, friendly, curious, accepting, compassionate and kind. 1 Mindfulness practices aim to cultivate mindfulness state. These practices can be formal (e.g. breathing, sitting, walking, body scan) or informal (e.g. mindfulness in everyday life). Many mindfulness-based intervention (MBI) programmes have been established. Among all the MBIs, mindfulness-based stress reduction (MBSR), which was launched by Jon Kabat-Zinn in 1979, 2 and mindfulness-based cognitive therapy (MBCT) by Segal, Teasdale and Williams based on MBSR, 3 , 4 are the two most widely adopted MBIs. These two programmes include eight weekly mindfulness sessions with one-day retreat.

Mindfulness is rooted in Buddhist traditions. However, it has become popular in recent years among various secular populations in healthcare, educational and workplace settings: from pre-school children to older adults across the world. Publications on mindfulness have increased dramatically in the recent decade. The publications on mindfulness is starting to be more comparable to publications on cognitive behavioural therapy (CBT), which is one of the most widely used psychotherapies ( Fig. 1 ).

Comparison on number of publications: mindfulness vs. CBT trials (by August 2020) [Note: Search terms included (‘mindful* or meditate*’ AND ‘trial or random or random* control* trial*’); (‘cognitive behavioural therapy or cognitive behavioural therapy or CBT’ AND ‘trial or random or random* control* trial*’) in Title; Databases included MEDLINE, EMBASE and PsycINFO.]

Methods used for identifying relevant evidence

Literature in English was searched in MEDLINE, EMBASE, CINAHL, PsycInfo, AMED, Web of Science and Google Scholar using keywords including ‘mindfulness’, ‘meditation’ and ‘review’, ‘meta-analysis’ or their variations, with no restrictions on the year of publication. The search was conducted in July 2020. In choosing evidence, these general principals were applied: (i) published in more recent years if similar reviews were identified; (ii) included randomized controlled trials or meta-analysis in the review; (iii) presented with more conclusive conclusions. Literature with other types of study design (e.g. randomized controlled trials, cohorts, cross-sectional studies) were also manually searched and included when no systematic review was found or when considered as appropriate. However, while it was intent to include all important literature in a certain area, the review might not exhaust all relevant literature but had only selected key references of interest that we thought to be most pertinent and insightful for a specific topic.

Effects on mental health

MBIs have been shown to be efficacious in improving some of the common mental health problems. 5

Depression and anxiety

For depression and anxiety, the efficacy of MBIs is sufficiently confirmed with meta-analyses demonstrating moderate to strong effect sizes for the reduction of the two conditions. 6–8 The effects were also applicable during pregnancy, where a systematic review showed that MBIs helped reducing perinatal anxiety of moderate to large magnitude; however, the effects were less consistent in terms of reducing perinatal depression. 9 The trending web-based interventions on mindfulness have also shown effectiveness in reducing depression and anxiety among people diagnosed with anxiety disorders as well. 10 It was unclear, however, whether the benefits of mindfulness practices as a stand-alone intervention still exist, as it is difficult to dismantle the effects from social interaction and psychoeducation, which are the other components integrated in many MBIs (e.g. group MBCT), from standalone mindfulness practices. Therefore, a recent meta-analyses 11 of 18 eligible studies investigated the gap, and has demonstrated that even mindfulness practice itself (e.g. breathing space, body scan, sitting meditation, soundscan) had small to medium effects on both anxiety (SMD = 0.39; CI: 0.22, 0.56; PI: 0.07, 0.70; P  < .001, I 2  = 18.90%) and depression (SMD = 0.41; CI: 0.19, 0.64; PI: −0.05, 0.88; P  < .001; I 2  = 33.43%).

Current evidence overall supports a moderate effect of MBIs on reducing stress; however, more robust studies are needed to make clear conclusions among different populations. A meta-analysis of five randomized control trials tested the effects of MBIs on cortisol levels, a stress-mediated hormone, and found that there may be a beneficial effect in healthy adult populations. 12 Yet, the overall effect size was moderately low ( g  = 0.41; P  = 0.025). 12 On the other hand, another meta-analysis indicated that there was a significant, medium effect of meditation interventions on cortisol levels, but the effect was only present for at-risk samples such as those living in stressful life situations. 13 There are also studies done among specific populations such as tertiary education students 14 and older adults, 15 showing inconclusive results. Among tertiary education students, the effect sizes of interventions for stress were moderate ( g  = 0.42, 95% CI: 0.27–0.57), but most studies were of poor quality. 14 Among older adults, no clear evidence was found that MBIs can reduce the perception of stress. 15

The current evidence on the effects of MBIs on insomnia and sleep disturbance is promising. A meta-analysis concluded that MBIs are effective in improving symptoms of insomnia and sleep quality when compared to attention/education and waitlist control with medium to large effects ( g  = 0.67, 95% confidence interval [CI] = 0.30–1.05) and that the effects seem to endured at 3 months postintervention ( g  = 1.06, 95% CI = 0.48–1.64). 16 Several other meta-analyses also found similar results, which all showed significant improvement in insomnia or sleep quality as measured by the Pittsburgh Sleep Quality Index. 17–19

Eating disorders

Current studies provided preliminary evidence on the potential effects of MBIs on eating disorders (EDs). One systematic review and meta-analysis showed a within-condition effect of MBIs on ED symptoms, emotional eating, negative affect and body dissatisfaction, and on the body mass index (BMI) in anorectic and bulimic participants relative to pre-assessment. 20 Another systematic review and meta-analysis also found that MBIs may help reducing body image concern and negative affect, while promoting body appreciation. 21 Both authors concluded that more rigorous studies are needed before the efficacy of MBIs on EDs can be confirmed. 20 , 21

Literature supports the efficacy of MBIs in both substance and behavioural addictions. A systematic review of 54 randomised controlled trials found that MBIs were successful in the reduction of dependence, craving and other symptoms related to addiction, and the improvement of mood state and emotion dysregulation. 22 Two other meta-analytic results also revealed significant small-to-large effects of MBIs in reducing levels of perceived craving, 23 , 24 severity of stress, 23 , 24 frequency and severity of substance misuse, 23 anxiety and depressive symptoms, 24 negative affectivity, 24 and post-traumatic symptoms 24 for the treatment of substance misuse. Although the effectiveness is promising, more research is needed especially on longer follow-up assessments and among diverse populations.

It seems that MBIs have potential benefits for people with psychosis, but further research is warranted. 25 A systematic review and meta-analysis on 434 patients found short-term moderate evidence of MBIs on total psychotic symptoms, positive symptoms, hospitalization rates, duration of hospitalization, and mindfulness as short-term effects and total psychotic symptoms and duration of hospitalization as long-term effects in patients with psychosis. 26 Another systematic review also confirmed that MBIs are feasible for individuals with psychosis and it could provide a number of significant benefits over routine care such as improving negative symptoms and measures of functioning. 27 Future large trials adopting randomization procedure are suggested to gain greater insight into the mechanisms and long-term effectiveness of MBIs among people with psychosis.

Post-traumatic stress disorder

MBIs among post-traumatic stress disorder (PTSD)-diagnosed participants were less conclusive. A systematic review and meta-analysis of 10 trials on meditation interventions have shown that the effects for PTSD were positive but not statistically significant. 28 The variety of meditation intervention types, the short follow-up times and the quality of studies limited the analyses. 28 Other systematic reviews reported similar findings, where they reported MBIs such as mindfulness, yoga and relaxation studies maybe useful for the mind–body treatments for PTSD but many of the trials suffered from methodologic weaknesses or were of low to moderate methodological rigor. 29 , 30 Further high-quality studies are needed on MBIs among PTSD-diagnosed participants in order to increase confidence in its effectiveness.

Attention-deficit hyperactivity disorder

There is a need for further research before determining the effectiveness of MBIs on attention-deficit hyperactivity disorder (ADHD) despite current studies showed that it can be a promising intervention. A systematic review and meta-analysis has found statistically significant effect of MBIs in decreasing the severity of ADHD core symptoms such as inattention, hyperactivity or impulsivity (children/adolescents: Hedge’s g  = −0.44, 95% CI −0.69 to −0.19, I 2 0%; adults: Hedge’s g  = −0.66, 95% CI –1.21 to −0.11, I 2 81.81%). 31 However, the authors concluded that there is insufficient methodologically sound evidence to support the effectiveness due to limited number of studies, heterogeneity across studies and high risk of bias. 31 Similar results and conclusions were also noted in several other systematic reviews. 32–34

Autism spectrum disorders

Current literature on MBIs for people with autism spectrum disorders (ASD) or their carers is very limited. A systematic review done in 2017 analysed 16 eligible studies but definitive recommendations could not be made on the effects of MBIs for people with ASD or their carers. 35 This was because those studies included very diverse age groups and outcome measures, including behavioural, social and psychological symptoms, as well as the subjective well-being of children and adults with ASD and their parents. 35 Overall, there may be some potential benefits of MBIs among people with ASD, these include: reducing anxiety, 35 , 36 thought problems, 35 , 36 rumination, 35 aggression, 36 parental stress 37 , and increasing subjective well-being 38 as well as parental psychological wellbeing. 37

The current available evidence to support MBIs on cognition is weak. A systematic review conducted in older adults with mild cognitive impairment found that MBIs improved participant’s cognitive function and everyday activities functioning. 39 However, the available studies had small sample sizes, lack of control comparison and lack of follow-up to understand the effects on preventing progression of dementia. 39 Further high-quality trials and on different populations are required to confirm the effectiveness of the benefits of MBIs on cognitive function.

Effects on physical health

MBIs can provide positive effects on physical health and evidence is strong regarding benefits of MBIs on the psychological symptoms among people with chronic diseases.

The evidence of benefits of MBIs on pain is abundant among different populations. 40 , 41 A systematic review and meta-analysis of 30 RCTs on chronic pain conducted in 2017 showed improvement on chronic pain management after mindfulness meditation intervention. 40 The percent change of the mean in pain for intervention subjects was −0.19% (SD, 0.91; min, −0.48; max, 0.10), which was significantly higher than the control groups (−0.08% (SD, 0.74; min, −0.35; max, 0.11)). 40 A network meta-analysis found MBSR is effective for chronic pain, and the effects are not significantly different between MBSR and CBT; though more studies are needed to confirm this. 41 Furthermore, for the effects of brief MBIs with a total contact time of less than 1.5 hours, current evidence is inadequate to confirm the effectiveness on acute and chronic pain. 42

Hypertension and cardiovascular diseases

A few systematic reviews and meta-analyses suggested that MBIs can reduce blood pressure (BP). 43–45 A systematic review and meta-analysis of five studies on MBSR showed reduction on systolic and diastolic blood pressure in people with hypertension or elevated blood pressure. However, most of the studies were related to clinical blood pressure only and evidence on ambulatory blood pressure is needed. 43 A systematic review among people with non-communicable diseases found systolic BP was reduced after the eight-week MBSR (−6.90 mmHg [95% CI: −10.82, −2.97]), followed by the 12-week breathing awareness meditation (−4.10 mmHg [95% CI: −7.54, −0.66]), and eight-week mindfulness-based intervention (−2.69 mmHg [95% CI: −3.90, −1.49]) and diastolic BP was reduced after eight-week MBSR (−2.45 mmHg [95% CI: −3.74, −1.17]) and the eight-week MBI (−2.24 mmHg [95% CI: −3.22, −1.26]). 44 Another systematic review among patients with CVD in 2020 showed benefits on systolic BP ( d +  = 0.89, 95% CI = 0.26, 1.51) and psychological symptoms ( d + s = 0.49–0.64), but not diastolic BP. 45 Another systematic review by Zou evaluated the effect of mindful exercises for patients after stroke showed significantly improvement on the sensorimotor function on lower limb (SDM = 0.79; 95% CI, 0.43–1.15; I 2  = 62.67%) and upper limb (SDM = 0.7; 95% CI, 0.39–1.01; I 2  = 32.36%). 46 Further studies can assess gait speed, leg strength, aerobic endurance, motor function, cognitive function and gait parameters.

Weight control and obesity

Overweight and obesity are a significant health risk factor leading to tremendous disease burden due to the associated comorbidities. 47 Mindful eating is an effective intervention for weight control, especially among people with binge eating or emotional eating tendency. Mindful eating might have longer-term effects when comparing to conventional diet programmes, which involves limiting energy intake and restricting food choices, because mindful eating tends to be more sustainable and also deal with emotional problems that may influence unhealthy diet. 48–52 A systematic review and meta-analysis in 2019 evaluated ten mindful eating and weight control studies, and found significant weight reduction after mindful eating program when compared with control groups (−0.348 kg, 95% CI: −0.591 to −0.105). 53 Furthermore, effects of MBIs were equal to conventional diet programmes. 53 However, limitations were found in the studies, such as short duration and biased samples (unbalanced sex ratio, source and place of living). Hence, further studies with longer duration and modifications of subject selection could be beneficial to evaluate long-term improvement among different populations.

The current evidence to support the effect of MBIs on the physiological outcomes of diabetes is inconclusive. One systematic review found mixed results on the effectiveness of MBIs for physiological outcomes (glycaemic control and blood pressure) on both types 1 and 2 diabetes patients. 54 Another systematic review and meta-analysis found that meditative movements significantly improved the glycaemic control including fasting blood glucose, glycated haemoglobin (HbA1c) and postprandial blood glucose in type 2 diabetes mellitus (T2DM) patients. 55 Nonetheless, the authors noted it is difficult to conclude the extent to which MBIs are effective because of the small sample size, short duration and diverse delivery methods within the published studies. 55 Apart from glycaemic control, systematic reviews also found improvement in psychological symptoms such as anxiety, 54 distress symptoms, 54 , 56 depression 54 , 57 and quality of life. 57 Further research addressing the limitations is necessary to gauge the efficacy of MBIs for diabetes.

There may be some benefits of MBIs on the physical health outcomes in cancer patients especially on cancer-related fatigue and pain, besides psychological benefits. 58 , 59 A systematic review and meta-analysis found that MBIs led to a statistically significant reduction in cancer-related fatigue (CRF) score among cancer patients (SMD = -0.51, 95%CI [−0.81–0.20]), 59 especially among lung cancer patients. 60 Apart from CRF, a range of other outcomes such as improvements in sleep disturbances, pain and other psychological symptoms including anxiety, depression, fear of cancer recurrence were also found in another systematic review and meta-analysis. 61 Overall, although MBIs appeared effective in reducing CRF and other symptoms, further high-quality studies are still required to provide additional insights and to confirm the existing evidence.

Respiratory health (COPD, asthma, etc.)

The effectiveness of MBIs on respiratory health remained unclear. A systematic review and meta-analysis of 16 studies found that meditative movement may have the potential to enhance lung function and physical activity in Chronic obstructive pulmonary disease (COPD) patients. 62 When compared to nonexercised group, the intervention enhanced the 6-minute walking distance (3 months: mean difference [MD] = 25.40 m, 95% CI: 16.25–34.54; 6 months: MD = 35.75 m, 95% CI: 22.23–49.27), as well as functions on forced expiratory volume in 1 s (FEV 1 ) (3 months: MD = 0.1 L, 95% CI: 0.02–0.18; 6 months: MD = 0.18 L, 95% CI: 0.1–0.26). 62 However, taking into considerations of the limitations of the studies such as small sample sizes, inconsistency in study quality and the diverse style of meditative movement in studies, the authors noted that further trials are needed to substantiate the findings. 62 Other systematic reviews and meta-analyses on COPD 65 and asthma 63 also concluded that further high-quality trials are needed to confirm the effectiveness of MBIs on respiratory health. 63 , 64

Effects on social health and prosocial behaviours

There is evidence supporting effects of MBIs on social health and prosocial behaviours (i.e. voluntary behaviour intended to benefit another). 65 , 66 A systematic review found medium effects on prosocial behaviours for both correlational and intervention studies, and the effects are similar to known and unknown others. 65 The results suggest that mindfulness fosters ethical and cooperative behaviour across a range of interpersonal contexts and may reduce intergroup biases. 65 Another recent review with 29 studies also find similar results with small to medium effect sizes, suggesting MBIs reliably improve compassionate helping and reduces prejudice and retaliation. 66 Furthermore, MBIs can effectively reduce anger, 67 violence 68 and aggression. 69 It also may help improve social and ecological sustainability, by improving individuals’ subjective well-being and benign connection with others, the society and the nature. 70

Loneliness and social isolation are an increasing public health concern, especially during COVID-19 and for older adults. Some preliminary studies indicated that mindfulness training might have positive effect in mitigating loneliness. 71–74 A preliminary study showed MBSR effectively reduced loneliness in older adults. 71 Another study found positive effect on mitigating the loneliness of women with HIV. 72 A study among Chinese college students found a positive relationship between mindfulness and loneliness reduction. 73 Lindsay et al. raised that mindfulness both reduced loneliness and increased social interactions in daily life compared with an active control program, in the experiment of smartphone-based mindfulness training. 74

Mindfulness in different settings

Mindfulness among professionals in healthcare settings.

Mindfulness has been adopted as a stress management tool for healthcare professionals, with a medium effect size was found ( r  = 0.342, CI = 0.202–0.468). 75 Systematic reviews and meta-analyses have shown the promising effects on the other psychological indicators among healthcare professionals and students, e.g. reducing depression and burnout and improving emotional resilience. 76 , 77 However, both benefits and challenges (time limitations and feasibility) were perceived at the same time, 78 and there are insufficient studies on indirect outcomes of MBIs among healthcare professionals, e.g. how it may influence professional-patient communication, relationship and patient outcomes.

Mindfulness in schools

Mindfulness programmes in schools are increasingly popular. Many different school mindfulness programmes (e.g. ‘.b’, mindful schools, well and resilience program) have been implemented across the world. 79 , 80 These programmes can target at students, teachers, and even parents or caregivers. 81 Recent systematic reviews found MBIs hold promises in particular in improving resilience to stress, cognitive performance such as attention, and emotional problems in children and youths. 82 , 83 The reviews showed a significant effect for resilience in regards to well-being, positive and constructive emotions or affect, social skills and positive relationships, self-concept and self-esteem. The effects (effect size = 0.36–0.80) are comparable or better than the effects (overall effect size = 0.30) of school-based social and emotional learning programs as revealed in the meta-analysis. 84 It is promising in applying MBIs as a life skill within pre-, elementary, middle or high schools. Students might be benefited from 90-min mindfulness practice per week (i.e. 18 minutes on average per day). 85 In building up mindful schools, a whole school approach is valuable to integrate mindfulness through the curriculum, professional development of teachers, leadership practice and across the learning environment. 86

Mindfulness in workplace

A systematic review on 58 592 adults from nonclinical samples showed that trait mindfulness was positively associated with confidence, job satisfaction, performance and interpersonal relations, and negatively associated with burnout and work withdrawal. 87 A recent systematic review on 56 randomized controlled trials shows that MBIs are beneficial to employees in reducing stress, burnout, mental distress and somatic complaints, while improving mindfulness, well-being, compassion and job satisfaction—all with small to large effect sizes ranging from Hedge’s g  = 0.32–0.77, but effects on work engagement and productivity were limited by low number of studies. 88

Cost-effectiveness of MBIs

MBIs are likely to be cost-effective and value for money as it can be provided in group format or as self-help interventions, 89 and it can also be integrated into educational programmes for clinicians, educationalists and other professionals to directly and indirectly benefit themselves, students, their clients and people around them. 90 While the benefits are almost equal to cognitive behavioural interventions, mindfulness may require less professional training and take less time for both workers and clients to master, and they are probably less expensive to provide. 91 For example, studies showed that the training cost for teachers in a mindfulness training program ranged from US$515 to US$1850 per teacher depending on the number of teachers being trained and the ancillary and opportunity costs. 92 However, more studies are needed to confirm their cost-effectiveness. Preliminary evidence support its cost-effectiveness, 93 including but not limited to pain in breast cancer, 94 fibromyalgia, 95 low back pain 96 and caregiver training. 97 It is also a cost-saving treatment for improving quality of life for distressed cancer patients using both online or face-to-face MBCT. 98 However, uncertainties existed in workplace, 99 and yet it needs cost-effectiveness studies on many other health problems aswell.

Compliance of MBIs

Non-compliance is a barrier to learning mindfulness 100 and research shows that the drop-out rate can reach 25% or higher. 101 , 102 Inconsistent findings were shown in previous studies regarding who might or might not comply with MBIs. Although in general, women, those with higher openness to experience, higher resistance to change and severer symptoms showed higher levels of compliance. 103 , 104 The relationship between participants’ compliance and intervention outcomes is inconsistent, ranging from no correlation to a positive correlation, 105 although one recent systematic review based on 28 studies found a small but significant association between participants’ self-reported home practice and intervention outcomes ( r  = 0.26, 95% CI: 0.19–0.34). 106 In terms of factors associated with better compliance, a good natural setting is found to be important, especially for beginners. 100 And some researchers suggested to identify meditation exercises that can balance optimizing effectiveness and enhancing adherence to strengthen the compliance to MBIs. 107 It still needs more research to understand who might comply with and benefit from which type of MBIs the most, and to look into factors and strategies enhancing compliance.

Mechanisms of MBIs

Studies suggested that the mechanisms of MBIs include changes in mindfulness, rumination, worry, self-regulation, compassion or meta-awareness, which predicted or mediated the treatment effects, which are theoretically predicted mechanisms of MBIs. 108–111 Preliminary results also suggested alterations in attention, memory specificity, self-discrepancy, emotional reactivity and momentary positive and negative affect, can be part of the mechanisms. 108 Recently, the mindfulness-to-meaning (MMT) approach has also been recognized as providing a theoretical framework to investigate specific mindfulness components and their contributions to the positive health outcomes. 112 , 113 In this approach, the iterative cycle of appraisal, decentering and metacognition would lead to positive reappraisals of broader contexts that extinguish negative affect and promote positive effects and eudaimonic meaning in life. 112 , 113 Yet, there are still many unknowns regarding the mechanisms ofMBIs.

Neurophysiological findings

The changes on brain and biomarkers of immune function and stress might have provided neurophysiological basis for explaining the positive effects of MBIs. Systematic reviews have consistently found effects of MBIs on brain activity that involves in processing self-relevant information, self-regulation, focused problem-solving, adaptive behaviour and interoception, among both healthy populations and patient groups. 114–119 Eight brain regions key to meta-awareness (frontopolar cortex), body awareness (sensory cortices and insular), memory consolidation and reconsolidation (hippocampus), self and emotion regulation (anterior and mid cingulate; orbitofrontal cortex), and intra- and interhemispheric communication (superior longitudinal fasciculus; corpus callosum) consistently altered with a medium effect size after mindfulness practices. 118 In expert meditators, both functional and structural brain modifications have been induced, especially in areas involved in self-referential processes such as self-awareness and self-regulation, though not enough evidence suggests structural brain modifications in short-term meditators. 114 Among people with major depressive disorders, MBIs have also modulatory effects on several brain regions (e.g. the prefrontal cortex, the basal ganglia, the anterior and posterior cingulate cortices and the parietal cortex). 115 Another systematic review on 78 functional neuroimaging (fMRI and PET) studies of meditation found patterns of brain activation and deactivation for common styles of meditation (focused attention, mantra recitation, open monitoring and compassion/loving-kindness), with medium effects for both activations ( d  = 0.59) and deactivations ( d  = −0.74), suggesting potential practical significance. 116 The systematic review on EEG results suggested that mindfulness is associated with increased alpha and theta power in both healthy populations and patient groups, which may signify a relaxed alertness state contributing to mental health. 117

Systematic reviews on RCTs revealed that mindfulness meditation have effects on stress and immune-related physiological markers of inflammation, cell-mediated immunity and biological aging: reductions in the activity of the cellular transcription factor NF-kB, reductions in circulating levels of C-reactive protein, increases in CD4+ T cell count (in HIV-diagnosed individuals), and increases in telomerase activity. 120 Another systematic review on RCTs found that, compared to an active control (relaxation, exercise or education), mindfulness meditation reduced physiological markers of stress, such as cortisol, C-reactive protein, systolic blood pressure, heart rate, triglycerides and tumour necrosis factor-alpha, in various populations. 121 And a greater number of hours of meditation are associated with a greater impact on telomere biology. 122 However, these tentative findings need further replication and the review authors call for studies to include physiological markers as primary outcome of RCTs. 120–123

Ethics of MBIs

Ethical questions are fundamental and essential in guiding the future directions of MBIs to use the right mindfulness rightly, and also the application of MBIs should not overstate the organizational and social determinants of ill health. In the books of ‘Practitioner’s Guide to Ethics and Mindfulness-Based Interventions’ (edited by Lynette Monteiro, Jane Compson and Frank Musten) and ‘Handbook of Ethical Foundations of Mindfulness’ (edited by Stanley Steven, Ronald Purser and Nirbhay Singh), ethical questions of mindfulness are discussed extensively. Many questions on ethics are yet to be addressed for MBIs. For example, paradox in teaching mindfulness in business and military settings, depriving superiors to make use of subordinates through mindfulness regardless of other organizational factors causing work-related stress or depression. On the other hand, there are many virtues and strengths in MBIs in providing personally meaningful and prosocial values, 124 and MBIs can improve ethical standards, that mindfulness promotes greater ethical intentions and lesser ethical infractions, with more mindful people revealed a greater emphasis on moral principles than those who are less mindful. 125

Safety of MBIs

MBIs are regarded as relatively safe interventions. 126 Like many other psychological intervention trials, adverse events and adverse effects of MBIs are largely underreported. A previous systematic review on safety of MBSR and MBCT indicated that fewer than one in five trials had mentioned the monitoring of adverse effects. 126 Program-related factors, participant-related factors, and clinician- or teacher-related factors are potential sources of adverse effects. 1 , 126–132 A safety checklist is yet needed to be built based on previous studies and empirical experiences. Practitioners and researchers in future MBI programmes are advised to report the potential adverse events using such a checklist, and also continue to take safety precautions such as screening and caring for vulnerable individuals. These individuals could be those with PTSD, seizure disorder/epilepsy, acute psychosis, mania, suicidality or other health problems of concern. 133

Future directions

Despite the increasing trend of mindfulness studies and applications, there are still many areas need exploration. First, higher quality of research studies is needed. The most frequent limitations mentioned in the systematic reviews on effectiveness and cost-effectiveness of MBIs are low quality of study design, small sample size, short follow-up period, and inconsistent terminology and measurement tools. Future more robust studies are needed to address these caveats. Second, more studies on online MBIs intervention and training are needed to understand if online alternatives have equal or better effects and cost-effectiveness, though preliminary benefits are seen. 10 , 134 , 135 Online alternatives might be important, especially given the pandemic of COVID-19. Third, more understanding of the mechanisms by integrating both empirical findings and neurophysiological findings. Fourth, more research is needed to explore the acceptance and compliance of MBIs to understand who might benefit more from MBIs, and barriers and respective strategies (e.g. better meditation environment) for improving the acceptance and compliance, taken into considerations of safety issues and ethical concerns. And a closer look at the long-term compliance is needed. This may call for large-scale cohort studies on MBIs. Fifth, develop more mindfulness related research and services guidelines and regulations, e.g. on adverse events monitoring and safety guarantee, and qualifications of mindfulness teachers. These might be important when MBIs are provided as a collective action in schools, companies or organizations. Sixth, exploration of Mindfulness Plus (Mindfulness+), i.e. combination of MBIs with other effective interventions (for example, mindfulness plus medications, mindfulness plus behavioural activation, 136 mindfulness plus reflection training 137 and mindfulness plus Qigong movement therapy 138 ), or exploration of personalized/individualized mindfulness-based interventions for individuals with different characteristics and needs, selecting from many different mindfulness programs. This would provide more potential to improve the effects of MBIs for different goals.

MBIs are effective for many common mental, physical and social health conditions among different populations. Beneficial effects of MBIs have been found on depression, anxiety, stress, insomnia, addiction, psychosis, pain, hypertension, weight control, cancer-related symptoms and prosocial behaviours. Current evidence suggested MBIs can be beneficial for healthcare professionals and within schools and workplaces although more studies are still needed to look into its efficacy on many different biopsychosocial health conditions. MBIs are relatively safe. Ethical aspects should always be taken into account during mindfulness-based trainings and interventions. Mechanisms of MBIs have been suggested in both empirical and neurophysiological findings. Cost-effectiveness is found for some health problems (e.g. breast cancer, fibromyalgia, low back pain or caregiver training). More high-quality studies with adequate sample size and longer follow-up duration are needed to confirm its effectiveness and cost-effectiveness in many other problems and among sub-groups. Some other areas needing additional research are suggested in this review.

Contributor Information

Dexing Zhang, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China; Thomas Jing Mindfulness Centre for Research and Training, The Chinese University of Hong Kong, Hong Kong SAR, China.

Eric K P Lee, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China; Thomas Jing Mindfulness Centre for Research and Training, The Chinese University of Hong Kong, Hong Kong SAR, China.

Eva C W Mak, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China; Thomas Jing Mindfulness Centre for Research and Training, The Chinese University of Hong Kong, Hong Kong SAR, China.

C Y Ho, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China; Thomas Jing Mindfulness Centre for Research and Training, The Chinese University of Hong Kong, Hong Kong SAR, China.

Samuel Y S Wong, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China; Thomas Jing Mindfulness Centre for Research and Training, The Chinese University of Hong Kong, Hong Kong SAR, China.

Conflict of interest statement

Data availability statement.

There are no new data associated with this article.

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• Published: 19 April 2021

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

• Joep van Agteren   ORCID: orcid.org/0000-0002-7347-7649 1 , 2 ,
• Matthew Iasiello   ORCID: orcid.org/0000-0003-1449-602X 1 , 2 , 3 ,
• Laura Lo 1 ,
• Jonathan Bartholomaeus 1 , 4 , 5 ,
• Zoe Kopsaftis   ORCID: orcid.org/0000-0002-9189-1405 6 , 7 , 8 ,
• Marissa Carey 1 &
• Michael Kyrios   ORCID: orcid.org/0000-0001-9438-9616 1 , 2 , 9  

Nature Human Behaviour volume  5 ,  pages 631–652 ( 2021 ) Cite this article

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• Outcomes research
• Quality of life

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations ( n  = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

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Acknowledgements

The authors thank colleagues at the South Australian Health and Medical Research Institute, Wellbeing and Resilience Centre, for their support during the creation of this review, S. Brown and N. May, for their help in crafting the search strategy. This work was supported by a grant by the James and Diana Ramsay Foundation. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

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Joep van Agteren, Matthew Iasiello, Laura Lo, Jonathan Bartholomaeus, Marissa Carey & Michael Kyrios

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Joep van Agteren, Matthew Iasiello & Michael Kyrios

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J.v.A.: review methodology, screening of literature, data extraction, risk of bias, meta-analysis and writing. M.I.: review methodology, screening of literature, data extraction, risk of bias and writing. L.L.: screening of literature, data extraction, risk of bias and writing. J.B.: data extraction, risk of bias and writing. Z.K.: risk of bias and writing. M.C.: data extraction and writing. M.K.: input into methodology, focus of review and writing.

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van Agteren, J., Iasiello, M., Lo, L. et al. A systematic review and meta-analysis of psychological interventions to improve mental wellbeing. Nat Hum Behav 5 , 631–652 (2021). https://doi.org/10.1038/s41562-021-01093-w

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Accepted : 05 March 2021

Published : 19 April 2021

Issue Date : May 2021

DOI : https://doi.org/10.1038/s41562-021-01093-w

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