Mindfulness training accelerates anxiety and depression relief via enhanced psychological resilience

Abstract

BACKGROUND

Anxiety and depression are prevalent and often co-occurring mental health disorders. While mindfulness training has shown efficacy in reducing symptoms, the underlying mechanisms, particularly the role of psychological resilience, remain underexplored. This study investigates whether mindfulness training alleviates anxiety and depression and hypothesizes that psychological resilience mediates this relationship.

AIM

To test whether mindfulness training eases anxiety and depression and whether resilience acts as a mediator.

METHODS

In an 8 weeks study, 133 patients with anxiety/depression symptoms were randomly divided into a control group (65 cases) and an observation group (68 cases). The observation group received structured mindfulness training alongside usual care. Pre-intervention and post-intervention assessments of anxiety, depression, mindfulness, and resilience were performed using the Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, Five Facet Mindfulness Questionnaire, and 10-item Connor-Davidson Resilience Scale, and the mediating role of psychological resilience was also examined.

RESULTS

At baseline the groups did not differ on gender, age, illness duration or employment status (P > 0.05). Post-intervention, the observation group showed significantly greater improvement than the control group, with lower Hamilton Anxiety Rating Scale (20.88 ± 2.52 vs 25.95 ± 2.61) and Hamilton Depression Rating Scale scores (21.24 ± 1.65 vs 26.37 ± 1.94), and higher Five Facet Mindfulness Questionnaire (125.37 ± 12.72 vs 112.14 ± 12.05) and 10-item Connor-Davidson Resilience Scale scores (34.53 ± 2.87 vs 28.31 ± 4.13) (P < 0.001). Bootstrapped mediation analysis (5000 samples) indicated that psychological resilience significantly mediated the intervention’s benefits, accounting for 9.89% of anxiety reduction (indirect effect = -0.498, 95%CI: -1.045 to -0.010) and 18.97% of depression reduction (indirect effect = -1.002, 95%CI: -1.570 to -0.327).

CONCLUSION

Mindfulness therapy lessens anxiety and depression both on its own and by boosting resilience, offering a dual pathway that makes it a valuable add-on treatment for these disorders.

Key Words: Mindfulness training; Psychological resilience; Mediating effect; Anxiety and depression disorders; Clinical application

Core Tip: This randomized controlled trial demonstrates that mindfulness training not only directly alleviates symptoms of anxiety and depression, but also enhances patients’ psychological resilience, which in turn partially mediates symptom reduction. The findings reveal a dual-pathway mechanism, offering a clinically feasible and culturally adapted intervention model to accelerate recovery.

INTRODUCTION

In clinical practice, anxiety disorders and depressive disorders are the most prevalent mental health issues. A study based on the Global Burden of Disease Study 2021 indicates that the disease burden of mental disorders among adolescents and young adults under the age of 24 is showing a continuous upward trend[1]. It is projected that by 2050, the number of disability-adjusted life years related to this issue will increase significantly. Anxiety disorders and depression disorders are the main contributing factors. This highlights the urgency of implementing early intervention measures.

In response to this serious challenge, non-pharmacological psychological interventions have increasingly become the focus of clinical practice and research. Among them, mindfulness training, as a psychological intervention method derived from Eastern Zen practice and systematized by Western psychology, has been widely used and supported by empirical evidence in recent years[2]. Its main goal is to develop a compassionate and accepting mindset by actively and nonjudgmentally monitoring the present situation[3]. Numerous studies have demonstrated the effectiveness of mindfulness-based therapies, including mindfulness-based stress reduction and mindfulness-based cognitive therapy, in reducing the symptoms of anxiety and depression and in preventing depressive relapse[4,5]. Existing research has preliminarily revealed that mindfulness may be effective through multiple pathways, such as improving emotion regulation, reducing rumination, and enhancing cognitive flexibility[6,7].

At the same time, individual differences play a crucial role in the occurrence and rehabilitation process of mental disorders. In recent years, psychological resilience – regarded as a pivotal personal trait resource – has been drawing growing interest from researchers. Specifically, psychological resilience is defined as an individual’s capacity to sustain positive adaptation, manage adversity, trauma, or significant stress effectively, recover from such challenges, and even achieve personal growth through them[8]. Extensive research has demonstrated that psychological resilience levels exhibit a marked negative correlation with symptoms of anxiety and depression; notably, high psychological resilience serves as a crucial protective factor for individuals against the risk of developing psychopathological conditions[9,10]. It is worth noting that mindfulness training may indirectly improve emotional symptoms by enhancing an individual’s psychological resilience, but this potential mediating pathway has not yet been systematically examined in the clinical population with comorbid anxiety and depression.

Against this backdrop, the present study intends to adopt a rigorously designed randomized controlled trial to implement mindfulness training among patients clinically diagnosed with anxiety and depressive disorders, with the goal of investigating the mediating effect of psychological resilience. This research not only contributes to a deeper understanding of the mechanism of mindfulness, but also provides theoretical basis and practical guidance for the development of more targeted and individualized psychological intervention strategies.

MATERIALS AND METHODS

General information

A total of 140 patients with anxiety and depression disorders who met the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition diagnostic criteria were recruited from the outpatient and inpatient services of the Department of Psychiatry at Chinese People’s Liberation Army General Hospital Seventh Medical Center between September 2023 and March 2025. According to the 1:1 grouping scheme, 70 cases were included in the control group and the observation group. After randomization, 7 patients (5.0%) withdrew consent before the intervention commenced. Ultimately, 133 patients completed the study protocol, with 68 cases in the observation group and 65 cases in the control group. Ultimately, the observation group included 68 cases, while the control group comprised 65 cases.

Inclusion criteria: (1) Meeting the diagnostic standards for anxiety and depressive disorders specified in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition[11]; (2) Being over 18 years of age; (3) Having no language communication barriers and being capable of understanding and complying with all treatment-related procedures; and (4) Having both the participants and their family members voluntarily signed the informed consent form.

Exclusion criteria: (1) Patients with major mental illness; (2) Patients with other serious physical illnesses; (3) Participating in other intervention programs or research activities concurrently; and (4) Being lost to follow-up during the study period. This research project has obtained official approval from the Ethics Committee of our hospital.

Methods

The control group received routine care, including basic medical care, medication management, daily routine care, and general health education. Nurses ensured patients took their medications on time, monitored for side effects, and provided necessary dietary guidance and daily activity arrangements. They also provided routine psychological counseling, but lacked systematic, targeted psychological interventions. The intervention period lasts for 8 weeks.

Based on the control group’s regular nursing care, the observation group received mindfulness training that mostly covered the following topics.

Establish a mindfulness intervention team: This team consists of the patient’s attending physician, psychological counselor, and nursing staff. Before the intervention begins, organize group training to ensure that each member understands the basic principles, operation procedures, and relevant precautions of mindfulness therapy. At the same time, systematically collect and organize the patient’s personal information and formulate a personalized intervention plan based on it.

Implement theoretical guidance: Through a 1.5-hour intensive lecture, the purpose and significance of mindfulness therapy were introduced to patients, and its core concepts, key elements, and meditation techniques were explained in detail to boost individuals awareness of the intervention and their willingness to cooperate.

Conduct breathing exercises: Instruct the patient to sit quietly with their eyes closed, focus their attention on the tip of their nose, and be aware of the breathing movements throughout the process. In the initial stage, complete 3-4 deep breaths to establish an attention anchor and experience the feeling of the airflow temporarily staying at the base of the skull; then guide the patient to feel the path of the air flowing through the upper limbs, arms, elbows and fingertips, and finally guide the consciousness to the throat and internal organs (liver, lungs, bladder and large intestine). Repeat 3 times to achieve full expansion and penetration of the respiratory organs. This exercise is designed to help patients become aware of the flow of air in the body during breathing, cultivate inner peace, and enhance the ability to regulate breathing autonomously.

Organize sensory training: Encourage patients to maintain an open attitude during the nursing process and fully accept the information input from the surrounding environment. Use mindfulness exercises to activate sensory experiences, help patients overcome psychological defenses, release repressed emotions, and enhance the exploration of known and unknown experiences, thereby improving emotional regulation ability. Guide patients to actively communicate with family members and others to improve their emotional state and social adaptability. In a quiet environment, with soothing music, implement muscle relaxation training, and meditate through language guidance. Carry out multi-sensory stimulation projects, covering taste, hearing, smell, vision and touch, etc., such as guiding patients to imagine tasting favorite foods to stimulate pleasure, playing preferred music to promote relaxation, and selecting appropriate smells for olfactory stimulation. Encourage patients to continue mindfulness practice at home to gradually enhance their ability to adapt to the environment.

Conduct stress tolerance training: This includes mindfulness practice, structured stress tolerance activities, and music relaxation training. During the training, peaceful music such as “Chengyuan Jixiang” can be played to help patients strengthen their self-awareness in a state of mental relaxation. At the same time, establish a good communication mechanism and pay attention to the quality of interaction between patients and medical staff, other patients, and their families to support their social integration process.

After the mindfulness training: Organize patients to have a group discussion, including training experience and feedback on the effect, cognition and coping with negative emotions, emotional balance strategies, stress management methods, and emotional catharsis channels. The results of the discussion will be systematically summarized to provide a basis for the optimization of subsequent intervention measures.

Intervention parameters and consistency: The mindfulness training protocol consisted of 16 group sessions (2 per week) over 8 weeks, each lasting 90 minutes (total direct contact: 24 hours). Participants were instructed to engage in daily home practice of 30-45 minutes, including breath-focused meditation, body scan, and informal mindfulness exercises (estimated total home practice: 28-42 hours). Total intervention dosage ranged from 52 hours to 66 hours. All sessions were led by a certified mindfulness instructor with > 5 years of experience and were delivered following a standardized manual. Session attendance was recorded; participants attending < 75% of sessions (i.e., < 12 sessions) were considered non-adherent (none in this study). Home practice was tracked via daily self-report logs.

Observation indicators

Demographics: (1) Gender; (2) Age; (3) Illness duration; and (4) Employment.

Symptom severity: The 14-item Hamilton Anxiety Rating Scale (0-56 points) and 17-item Hamilton Depression Rating Scale (0-52 points), higher scores indicate greater severity[12].

Mindfulness: The 39-item Five Facet Mindfulness Questionnaire (38-190 points) covering observe, describe, act with awareness, non-judge, and non-react, higher totals reflect stronger mindfulness[13,14].

Resilience: The 10-item Connor-Davidson Resilience Scale (0-40 points), elevated scores denote higher resilience[15].

Statistical analysis

Analyses were run in SPSS 22.0. The mean ± SD describe continuous variables; paired t-tests assessed pre-post change and independent t-tests compared groups. Categorical data are reported as n (%) and were examined with χ². Pearson correlations evaluated pairwise associations. Mediation was tested with the PROCESS 4.1 macro (model 4, 5000 bootstrap samples). A 95%CI excluding zero indicated a significant indirect effect; α = 0.05. The primary analysis followed the per-protocol principle. A sensitivity intention-to-treat analysis, using baseline observation carried forward for the 7 pre-intervention dropouts, was also conducted and confirmed the robustness of the primary findings.

RESULTS

Demographics

There was no significant statistical difference in the general data (gender, age, disease duration, and working status) between both groups (P > 0.05; Table 1).

Table 1 Demographics of both groups were compared, n (%)/mean ± SD.

Project	Control group (n = 65)	Observation group (n = 68)	t/χ²	P value
Gender			0.349	0.555
Male	32 (49.23)	30 (44.12)
Female	33 (50.77)	38 (55.88)
Age (years)	38.74 ± 13.40	38.84 ± 13.13	0.043	0.965
Illness duration (months)	11.37 ± 2.57	11.47 ± 2.16	0.246	0.806
Employment status			0.013	0.908
Working	54 (83.08)	57 (83.82)
Unemployed	11 (16.92)	11 (16.18)

Overview and inter-correlations of study variables

At baseline, anxiety and depression were strongly positively related (r = 0.873, P < 0.001), mindfulness and resilience were also positively linked (r = 0.814, P < 0.001), while higher anxiety/depression corresponded to lower mindfulness and resilience (P < 0.001; Table 2).

Table 2 Overview and inter-correlations of study variables (score), mean ± SD.

Project	mean ± SD	Anxiety		Depression		Mindfulness		Psychological resilience
		r value	P value	r value	P value	r value	P value	r value	P value
Anxiety	30.71 ± 2.65	1	-
Depression	32.38 ± 2.45	0.873	< 0.001	1	-
Mindfulness	86.29 ± 10.35	-0.883	< 0.001	-0.869	< 0.001	1	-
Psychological resilience	21.70 ± 4.15	-0.933	< 0.001	-0.872	< 0.001	0.814	< 0.001	1	-

Intervention effect test

Post-intervention, both groups showed lower Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale scores and higher Five Facet Mindfulness Questionnaire and 10-item Connor-Davidson Resilience Scale scores; the observation group improved significantly more (P < 0.05; Table 3).

Table 3 Intervention outcomes across groups (score), mean ± SD.

Project	Control group (n = 65)	Observation group (n = 68)	t value	P value
Anxiety (Hamilton Anxiety Rating Scale)
Before intervention	30.77 ± 2.64	30.66 ± 2.67	0.233	0.816
After intervention	25.95 ± 2.61a	20.88 ± 2.52a	11.390	< 0.001
Depression (Hamilton Depression Rating Scale)
Before intervention	32.42 ± 2.47	32.35 ± 2.44	0.146	0.884
After intervention	26.37 ± 1.94a	21.24 ± 1.65a	16.463	< 0.001
Mindfulness (Five Facet Mindfulness Questionnaire)
Before intervention	86.43 ± 10.43	86.15 ± 10.35	0.157	0.875
After intervention	112.14 ± 12.05a	125.37 ± 12.72a	6.153	< 0.001
Psychological resilience (10-item Connor-Davidson Resilience Scale)
Before intervention	21.94 ± 4.18	21.47 ± 4.13	0.649	0.517
After intervention	28.31 ± 4.13a	34.53 ± 2.87a	10.042	< 0.001

^aP < 0.05 vs before intervention.

Psychological resilience as a mediator

Hayes’ SPSS macro program PROCESS was employed to explore the mediating role of resilience in the association between mindfulness training and the reduction of anxiety and depression symptoms. A two-step mediation model was established, where group membership served as the independent variable (coded as 0 for the control group and 1 for the observation group), the post-intervention resilience score functioned as the mediator, and the post-intervention anxiety and depression scores acted as the dependent variables. The baseline scores of each variable were strictly controlled for in the model. Model 4 was selected, with a sampling frequency of 5000, a bootstrap sampling method using a nonparametric percentile method with bias correction, and a confidence interval of 95%. The findings demonstrated that the association between mindfulness training and the reduction of symptoms of anxiety and depression was partially mediated by resilience. For anxiety symptoms, the indirect effect of psychological resilience was -0.498, with a 95%CI: -1.045 to -0.0099; for depressive symptoms, the indirect effect was -1.002, with a 95%CI: -1.570 to -0.327. The direct effects in both pathways remained significant (P < 0.05), as shown in Figure 1 and Tables 4 and 5. By strengthening a person’s internal resources, specifically psychological resilience, mindfulness training can partially mediate the symptoms of anxiety and depression in addition to immediately reducing them. Notably, the mediating effect of resilience was stronger for depression (18.97%) than anxiety (9.89%). This differential mediation may reflect distinct psychopathological mechanisms: Depressive symptoms are more closely tied to intrinsic resource depletion (e.g., reduced self-efficacy, impaired emotion regulation) that resilience directly addresses, whereas anxiety symptoms may be more responsive to immediate physiological calming effects of mindfulness practice (e.g., reduced sympathetic arousal, breath-mediated relaxation). These findings suggest that mindfulness interventions may operate through dual pathways: (1) Direct symptom reduction via present-moment attention regulation; and (2) Indirect benefits via resilience-building that particularly supports recovery from depression.

Figure 1 Mediation effect model of psychological resilience. ^aP < 0.05, ^bP < 0.01, ^cP < 0.001.

Table 4 Examination of how psychological resilience mediates the relationship between anxiety disorders and mindfulness training.

Effect	Path	Effect size	SE	95%CI	Effect size
Total effect	Mindfulness training for anxiety	-5.046	0.164	-5.370 to -4.721
Direct effect	Mindfulness training for anxiety	-4.547	0.355	-5.249 to -3.845	90.11%
Indirect effects	Mindfulness training for mental resilience for anxiety	-0.498	0.261	-1.045 to -0.0099	9.89%

Table 5 Examining how psychological resilience mediates the relationship between mindfulness training and depressive illnesses.

Effect	Path	Effect size	SE	95%CI	Effect size
Total effect	Mindfulness training for depression	-5.282	0.206	-5.691 to -4.874
Direct effect	Mindfulness training for depression	-4.280	0.418	-5.108 to -3.452	81.03%
Indirect effects	Mindfulness training for mental resilience for depression	-1.002	0.317	-1.570 to -0.327	18.97%

DISCUSSION

Patients with anxiety and depression often experience recurrent symptom exacerbations and decreased social functioning due to negative rumination and impaired emotion regulation, compounded by stressful life events and insufficient social support. This increases the risk of chronicity and reduces quality of life[16-18]. While conventional medications and traditional psychological interventions can alleviate some symptoms, they are limited by high risks of adverse reactions and long intervention cycles, making it difficult to rapidly improve patients’ resilience and long-term prognosis[19,20]. Therefore, exploring safe and effective intervention models that can target and enhance psychological resources is crucial for optimizing clinical rehabilitation pathways for anxiety and depression. This study focused on the mediating mechanism of resilience, combining the emotion regulation benefits of mindfulness training with clinical intervention needs. Results showed that mindfulness training can enhance patients’ resilience and accelerate the alleviation of anxiety and depression symptoms, providing a successful strategy for clinical intervention in anxiety and depression, with promising application value.

This study systematically explored the clinical efficacy of mindfulness training for individuals with anxiety and depression through a placebo-controlled trial. For the first time, it validated the mediating role of resilience in the relationship between mindfulness training and symptom relief in this population. The results indicated that providing mindfulness training alongside routine care led to a significant reduction in patients’ anxiety and depression levels, while also enhancing their mindfulness and resilience. Consequently, the observation group achieved notably superior outcomes compared to the control group (P < 0.05). Of great significance, the mediation analysis revealed that resilience exerted a partial mediating effect on the relationship between mindfulness training and improvements in anxiety and depression symptoms, with the mediating effect accounting for 9.89% and 18.97% of the total effect on anxiety and depression symptoms, respectively. This suggests that mindfulness training not only directly alleviates symptoms but also indirectly exerts a therapeutic effect by enhancing individuals’ resilience resources. This finding is highly consistent with existing theoretical and empirical research[21,22]. Mindfulness training can directly reduce emotional symptoms by fostering people’s nonjudgmental awareness of present-moment experiences, which can help break the cycle of rumination and emotional avoidance typical of anxiety and depression[23,24]. At the same time, mindfulness practice promotes improved emotion regulation and enhanced cognitive flexibility, both core components of resilience[25-27]. As a key trait for individuals to maintain adaptability and resilience in the face of stress, its improvement can further buffer the impact of negative emotions and enhance individuals’ ability to sustain treatment responses, thereby forming a virtuous “mindfulness-resilience-symptom relief” pathway[28-30]. The mediation effect results of this study further refine the mechanism of action of mindfulness training. The mediating effect of resilience in depression remission (18.97%) was higher than that of anxiety (9.89%), possibly reflecting that depressive symptoms are more dependent on the accumulation and mobilization of individuals’ internal resources (such as self-efficacy and emotion regulation), while anxiety symptoms may be more directly affected by the immediate emotional calmness and physical relaxation effects of mindfulness practice. This difference suggests that mindfulness intervention strategies can be further customized for different symptom characteristics in future clinical applications. Furthermore, the mindfulness training program designed in this study integrates multiple components, including breathing exercises, sensory activation, stress management, and group discussions. This program adheres to the core elements of classic mindfulness interventions while also balancing clinical feasibility and cultural adaptability. The low dropout rate (7.14%) and high completion rate during the intervention demonstrate the program’s good acceptability and adherence, making it suitable for patients with anxiety and depression in Chinese clinical settings.

Several limitations of this study should be acknowledged. First, the per-protocol analysis, despite a supportive intent-to-treat analysis, may still be influenced by attrition bias. Second, the sample was drawn from a single hospital, which may affect the generalizability of findings to other cultural or clinical settings. Third, the absence of a long-term follow-up prevents conclusions about the durability of effects and the role of resilience in relapse prevention. Fourth, the reliance on self-report measures introduces the potential for reporting bias. Future research should employ multi-center designs with longer follow-up periods, incorporate blinded outcome assessments, and explore the specific components of mindfulness training that most effectively enhance resilience.

CONCLUSION

In summary, this investigation shows that mindfulness training is a valuable adjunctive treatment for reducing the symptoms of sadness and anxiety. This effect stems not only from the emotion regulation function of mindfulness itself but also, in part, from enhancing resilience, an intrinsic protective factor. This provides mechanistic support and optimization directions for the clinical application of mindfulness training. Future studies might continue to investigate the differing contributions of different meditation components (such as breathing exercises, body scans, and loving-kindness meditation) to resilience and symptom improvement, and validate their relapse prevention effects over longer follow-up periods.