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Alkan E, Kumar G, Ravichandran S, Kaushal SR, Salazar-de-Pablo G, Alerci L, Michaud-Feinberg J, Gutiérrez-Rojas L, Zorzi C, Klauser P, Golay P, Kramer U, Alameda L. Effectiveness of mindfulness based interventions in reducing depressive symptoms across mental disorders: A meta-analysis of randomized controlled trials. Psychiatry Res 2025; 348:116473. [PMID: 40187061 DOI: 10.1016/j.psychres.2025.116473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 02/15/2025] [Accepted: 03/29/2025] [Indexed: 04/07/2025]
Abstract
Mindfulness based interventions (MBIs) are increasingly recognised for their efficacy in treating depressive disorders. Depressive symptoms are prevalent across various disorders and can significantly impact outcomes, therefore being an important transdiagnostic target. Multiple randomized controlled Trials (RCTs) have explored this question in discrete disorders; however, evidence has never been meta-analysed transdiagnostically. The Prospero-registered (CRD42022352046) systematic review has been conducted on EMBASE, MEDLINE and PsychINFO using terms related to Randomised controlled trials, mindfulness and depression in clinical samples aged between 18 and 65. Random-effects models were performed to assess the effectiveness of MBIs, including Mindfulness based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavioural Therapy (DBT), on depressive symptoms transdiagnostically. We conducted sensitivity, heterogeneity analyses, publication bias assessments, meta-regressions and assessed quality. Thirty-five studies, including participants from 12 different diagnostic categories, were included. The results revealed that MBCT, ACT, DBT and others are efficacious in treating depressive symptoms across psychiatric diagnoses compared to active control conditions, all with significant effect sizes. MBIs are effective in reducing depressive symptoms across psychiatric disorders. They should be considered as a potential cost-effective tool to be systematically implemented, not only in those with depression but across mental health disorders.
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Affiliation(s)
- Ekin Alkan
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Geetanjali Kumar
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Shreya Ravichandran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Samiksha Rakesh Kaushal
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Gonzalo Salazar-de-Pablo
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry and Mental Health. Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain; Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Livia Alerci
- TiPP Program Department of Psychiatry, Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Joelle Michaud-Feinberg
- TiPP Program Department of Psychiatry, Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland; Institute of Psychotherapy, General Psychiatry Service, Department of Psychiatry, Lausanne University Hospital, and University of Lausanne, Switzerland
| | - Luis Gutiérrez-Rojas
- Department of Psychiatry and Psychiatry and Neurosciences Research Group (CTS-549), University of Granada, Granada, Spain
| | - Carline Zorzi
- TiPP Program Department of Psychiatry, Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Paul Klauser
- Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland; Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Philippe Golay
- TiPP Program Department of Psychiatry, Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland; La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Av. Vinet 30, Lausanne
| | - Ueli Kramer
- Institute of Psychotherapy, General Psychiatry Service, Department of Psychiatry, Lausanne University Hospital, and University of Lausanne, Switzerland
| | - Luis Alameda
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Departamento de Psiquiatría, Centro Investigación Biomedica en Red de Salud Mental (CIBERSAM), Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain; TiPP Program Department of Psychiatry, Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland.
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Zanini C, Enrico P, Pescuma V, Favalli V, Bressi C, Brambilla P, Delvecchio G. Assessing the efficacy of metacognitive therapy as monotherapy or adjunctive treatment in patient suffering from major depression and dysthimia: A comprehensive review of clinical trials. J Affect Disord 2025; 371:333-343. [PMID: 39557303 DOI: 10.1016/j.jad.2024.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 11/13/2024] [Accepted: 11/15/2024] [Indexed: 11/20/2024]
Abstract
BACKGROUND Depression is one of the most widespread diseases worldwide, with the highest rates of disability. Considering its chronic course, over the years several treatment options have been developed and validated, however still with high relapse rates. Therefore, in recent years, the so-called third wave psychotherapies have been developed for the treatment of psychiatric disorders. Among these, the Metacognitive therapy (MCT) has proven to be effective in treating depression. The aim of this review is to evaluate the efficacy of MCT as monotherapy or adjunctive treatment in reducing depressive symptoms in patients suffering from major depression or dysthymia. METHODS From bibliographic research in PubMed until December 2023, we retrieved 12 original studies meeting our research criteria. RESULTS The total sample of patients undergoing metacognitive therapy (MCT) included 376 individuals, while the control groups comprised 300 subjects, with a gender ratio of the participants of 0.48 %. The results show that metacognitive therapy is an effective approach in reducing depressive symptoms in patients with a diagnosis of depression or dysthymia when used as add-on therapy, with an efficacy comparable to CBT and superior to pharmacotherapy and as monotherapy, with an efficacy comparable to therapy with antidepressants compared to the control group and compared to cognitive-behavioral therapy with higher rates of reduction of depressive symptoms after treatment and at six months. Preliminary data also indicate its efficacy in terms of reduction of depressive symptoms in elderly people, suggesting its possible use in this population. LIMITATIONS The methodological heterogeneity in terms of treatment protocols of MCT and treatment control as well as the clinical heterogeneity of the sample employed may have limited the generalizability of the results. CONCLUSIONS The results suggest that the use of MCT, both as monotherapy and as an add-on treatment, is a valid therapeutic option for major depression, even at the later stages. However, further studies are needed for deeper our comprehension of the efficacy of MCT in depression.
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Affiliation(s)
- C Zanini
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - P Enrico
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, 20122 Milan, Italy
| | - V Pescuma
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, 20122 Milan, Italy
| | - V Favalli
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, 20122 Milan, Italy
| | - C Bressi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, 20122 Milan, Italy
| | - P Brambilla
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, 20122 Milan, Italy
| | - G Delvecchio
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, 20122 Milan, Italy.
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Kang HK, Bisht B, Kaur M, Alexis O, Worsley A, John D. Effectiveness of interpersonal psychotherapy in comparison to other psychological and pharmacological interventions for reducing depressive symptoms in women diagnosed with postpartum depression in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1399. [PMID: 38645302 PMCID: PMC11032640 DOI: 10.1002/cl2.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Postpartum depression (PPD) is a condition that can affect any woman regardless of ethnicity, age, party, marital status, income, and type of delivery. This condition is highly prevalent worldwide. PPD, if not treated timely, can affect the maternal-child bond and can have a detrimental impact on the future cognitive, emotional, and behavioral development of the child. Interpersonal psychotherapy (IPT) has been reported as an effective treatment of PPD in previous studies as this focuses on relationship and social support issues. Previous reviews conducted in developed nations have reported the superior efficacy of IPT in comparison to other treatment options. There is no systematic review conducted in low to middle-income countries on the efficacy of IPT on PPD. Therefore it was necessary to undertake a systematic review to assess the effectiveness of IPT in reducing the depression among postpartum women in low and middle-income countries (LMICs). Objectives The main aim of this systematic review was to assess the effectiveness of IPT alone or in conjunction with pharmacological therapy and/or other psychological and psychosocial interventions, in reducing depressive symptoms among women diagnosed with PPD residing in LMICs. Search Methods The systematic search encompassed several prominent databases and grey literature. Furthermore, experts specializing in the field of IPT were consulted to identify any relevant studies conducted in LMICs that fulfilled the predetermined eligibility criteria. The most recent search update was performed in July 2022. Selection Criteria The PICOS criteria were meticulously defined for this review as described. Participants: Postpartum women diagnosed with PPD in LMICs were included. Intervention: IPT either as a standalone treatment or in conjunction with pharmacological therapy was included. Comparison: any form of psychological therapy or pharmacological therapy, whether administered individually or in combination, was considered for comparison. Study designs: experimental and quasi-experimental, factorial designs, and quantitative components (experimental, quasi-experimental, factorial designs) of mixed methods designs were eligible to be included. Studies with single-group study designs and qualitative studies were excluded from the review. Data Collection and Analysis Two reviewers from our team conducted a rigorous screening process to determine the eligibility of articles for inclusion. This involved an initial evaluation of titles and abstracts, followed by a comprehensive assessment of the full text of selected articles. In instances where discrepancies arose between the two reviewers, resolution was achieved through discussion or consultation with a third author to establish a consensus. Following the screening process, two team members independently extracted pertinent information and data from the studies that met the inclusion criteria. The treatment effect of the intervention, in comparison to the control group, was subsequently analyzed utilizing the fixed effects model taking into account the small number of studies. Main Results A total of 17,588 studies were identified from various databases, and 6493 duplicate studies were removed. Subsequently, 9380 studies underwent independent title and abstract screening resulting in the exclusion of 9040 studies. 345 full texts were thoroughly assessed leading to the exclusion of 341 studies, finally including 4 studies for review. The four included trials were randomized trials and comprised a total sample size of 188 women diagnosed with PPD residing in LMICs. Among these studies, three compared IPT with usual treatment, while one study compared IPT with antidepressant medications (ADMs). In terms of the providers of IPT, in one study, IPT was administered by nurses, while psychologists delivered IPT in another study. In one study, community health workers were responsible for providing IPT. However, in one study, information regarding the specific providers of IPT was not available or reported. The primary outcome measure reported in all four studies was depression, assessed using the Edinburgh Postnatal Depression Scale (EPDS). The geographical distribution of the studies included; one conducted in Zambia, one in Kenya, one in Pakistan, and one in Iran. Out of the four studies, three were included in the meta-analysis, as missing data from one study could not be obtained. Based on the overall treatment effect, it was found that depression scores decreased significantly more in the IPT group compared to other interventions (usual treatment or ADMs) (standardized mean difference [SMD] -0.62, 95% confidence interval [CI] (-1.01, -0.23), Z = 3.13 (p = 0.002), χ 2 = 49.49; df = 2; p < 0.00001; I 2 = 96%; 3 studies, n = 136). Out of the three studies, two studies compared the effectiveness of IPT in reducing depression scores specifically when compared to the usual treatment, and in both studies, depression scores were reduced significantly in the IPT group as compared to the usual treatment group. Only one study directly compared the effectiveness of IPT with ADM, reporting that IPT was more effective than ADM in reducing depression scores among postpartum women. Regarding adverse outcomes, only one study reported suicidal ideation with one participant in the IPT group and two in the ADM group (RR 0.50, 95% CI (0.05, 5.30), p = 0.56, n = 78). The same study reported seven participants in the ADM group had adverse drug reactions as compared to none in the IPT group (RR 15.0, 95% CI (0.89, 254), p = 0.06, n = 78). Authors' Conclusions Our comprehensive search yielded a limited number of four studies conducted in such settings. Despite the scarcity of available evidence, the findings collectively suggest that IPT is indeed an effective treatment for reducing PPD when compared to usual treatment and pharmacological therapy. However given the low certainty of evidence, there is a need for further research in the form of well-designed randomized controlled trials with larger sample sizes and a reduced risk of bias. Such studies would greatly contribute to enhancing the strength and reliability of the evidence base regarding the effectiveness of IPT in the context of PPD in LMICs. The knowledge generated from future research endeavors would be highly valuable in guiding the development of more affordable and cost-effective treatment approaches for PPD in resource-limited settings.
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Affiliation(s)
| | - Bandana Bisht
- Department of PsychiatryGovernment Medical College & HospitalChandigarhIndia
| | - Manmeet Kaur
- Shaheed Kartar Singh Sarabha College of NursingSarabhaLudhianaIndia
| | | | | | - Denny John
- Faculty of Life and Allied Health SciencesM S Ramaiah University of Applied SciencesBangaloreKarnatakaIndia
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Schalla MA, Stengel A. The role of stress in perinatal depression and anxiety - A systematic review. Front Neuroendocrinol 2024; 72:101117. [PMID: 38176543 DOI: 10.1016/j.yfrne.2023.101117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/29/2023] [Accepted: 12/31/2023] [Indexed: 01/06/2024]
Abstract
Perinatal depression (PND) and anxiety affect around 20% of women, but available pharmacotherapy is not sufficiently effective in 20-60% of them, indicating a need for better understanding of these diseases. Since stress is a significant risk factor for PND, the aim was to examine the role of biological, environmental and psychological stress in PND and anxiety through a systematic literature search. Overall 210 studies were included, among which numerous rodent studies showed that perinatal stress induced depressive-like and anxious behavior, which was associated with HPA-axis alterations and morphological brain changes. Human studies indicated that the relationship between cortisol and perinatal depression/anxiety was not as clear and with many contradictions, although social and psychological stress were clearly positively associated with PND. Finally, oxytocin, synthetic neuroactive steroid and n-3 PUFA diet have been identified as potentially beneficial in the therapy of PND and anxiety, worth to be investigated in the future.
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Affiliation(s)
- M A Schalla
- Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 12203 Berlin, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Germany; Department of Gynecology and Obstetrics, Helios Clinic, Rottweil, Germany
| | - A Stengel
- Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 12203 Berlin, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Germany; German Center für Mental Health (DZPG), Site Tübingen, Germany.
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Torres-Giménez A, Sureda B, Roca-Lecumberri A, Andrés-Perpiñá S, Solé E, Gelabert E. Efficacy of contextual therapies in perinatal depression and anxiety: A systematic review and meta-analysis. J Psychiatr Res 2024; 169:209-223. [PMID: 38043257 DOI: 10.1016/j.jpsychires.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/14/2023] [Accepted: 11/15/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND There are previous meta-analyses on the efficacy of cognitive behavioral therapy or mindfulness-based therapies in the perinatal period, but no previous review has focused on contextual therapies as a whole. The aim of this study was to carry out a systematic review and meta-analysis of the efficacy of contextual therapies on depressive and anxious symptoms in women in the perinatal period. METHODS A systematic search for randomized clinical trials has been carried out in the PUBMED, CINAHL, Psyc-INFO and Cochrane Library search engines. For the quantitative synthesis, the Morris effect size measure has been used. RESULTS A total of 34 RCTs have been found, of which 30 have been used for meta-analysis. The mean effect size of the studies on depression scores was dppc2 = -0.81 (95% CI = -1.12 to -0.50), while it was dppc2 = -1.04 (95% CI = -1.54 to -0.53) in the case of studies on anxiety scores. These effect sizes decreased to medium effect sizes when corrected for publication bias. LIMITATIONS The main limitations are the quality of the included studies, publication bias, and the limited number of studies on contextual therapies other than mindfulness-based therapies. CONCLUSIONS In conclusion, this systematic review found a large number of efficacy studies on mindfulness-based therapies and a small number of studies on the other contextual therapies. The effect sizes found are consistent with previous meta-analyses in the perinatal period.
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Affiliation(s)
- Anna Torres-Giménez
- Unitat de Salut Mental Perinatal CLINIC-BCN, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Bàrbara Sureda
- Unitat de Salut Mental Perinatal CLINIC-BCN, Hospital Clínic, Barcelona, Spain
| | - Alba Roca-Lecumberri
- Unitat de Salut Mental Perinatal CLINIC-BCN, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Susana Andrés-Perpiñá
- Unitat de Salut Mental Perinatal CLINIC-BCN, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eva Solé
- Unitat de Salut Mental Perinatal CLINIC-BCN, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Estel Gelabert
- Departament of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Barcelona, Spain
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Leng LL, Yin XC, Ng SM. Mindfulness-based intervention for clinical and subthreshold perinatal depression and anxiety: A systematic review and meta-analysis of randomized controlled trial. Compr Psychiatry 2023; 122:152375. [PMID: 36841089 DOI: 10.1016/j.comppsych.2023.152375] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/21/2023] [Accepted: 01/28/2023] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES About one in four mothers will experience depression and anxiety during pregnancy and within their first year following childbirth. The meta-analysis aggregated the findings of randomized controlled trials (RCTs) evaluating the immediate post-intervention and maintenance effects of MBI on perinatal depression and anxiety. METHODS A systematic search was conducted in PubMed, PsycINFO, Medline, Scopus, and Web of Science for English-language journal articles from the first available date until Oct 27th, 2022. RESULTS Twenty-five published RCTs were identified and reviewed, with a total of 2495 perinatal women. MBI was superior to controls for clinical and subthreshold perinatal depression and anxiety. The benefit for depression reduction was stable over time and sustained to the postpartum period, but the maintenance effect on perinatal anxiety was less conclusive. Moreover, MBI's post-intervention effects on depression and anxiety were moderated by perinatal women's symptom severity. The post intervention effects were significantly greater among women in Low- and Middle-Income countries, where perinatal mental health care is less available and accessible. Greater improvement in mindfulness was also associated with a significantly larger post-intervention effect on perinatal depression. CONCLUSIONS This meta-analysis suggests that MBIs may complement and extend the available range of effective interventions for clinical and subthreshold perinatal depression and anxiety.
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Affiliation(s)
- Ling Li Leng
- The Department of Sociology, Zhejiang University, Hangzhou, China.
| | - Xi Can Yin
- School of Humanities, Southeast University, Nanjing, China
| | - Siu Man Ng
- Social Work and Social Administration Department, The University of Hong Kong, China
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Liu C, Chen H, Zhou F, Long Q, Wu K, Lo LM, Hung TH, Liu CY, Chiou WK. Positive intervention effect of mobile health application based on mindfulness and social support theory on postpartum depression symptoms of puerperae. BMC Womens Health 2022; 22:413. [PMID: 36217135 PMCID: PMC9549653 DOI: 10.1186/s12905-022-01996-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study investigated the effects of mobile health application designed based on mindfulness and social support theory on parenting self-efficacy and postpartum depression symptoms of puerperae. METHODS We recruited 130 puerperae from a hospital in China and randomized them to an App use group (n = 65) and a waiting control group (n = 65). The App group underwent an 8-week app use intervention while the control group underwent no intervention. We measured four main variables (mindfulness, perceived social support, maternal parental self-efficacy and postpartum depressive symptoms) before and after the App use intervention. RESULTS In the App group, perceived social support, maternal parental self-efficacy were significantly higher and postpartum depressive symptoms was significantly lower. In the control group, there were no significant differences in any of the four variables between the pre-test and post-test. CONCLUSIONS Our findings indicated that the mobile health application may help to improve perceived social support, maternal self-efficacy and reduce postpartum depressive symptoms. The finding of the mobile health application's effect extends our understanding of integrative effects of mindfulness and perceived social support on reduction of postpartum depressive symptoms and suggests clinical potentials in the treatment of postpartum depressive symptoms.
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Affiliation(s)
- Chao Liu
- grid.495500.d0000 0004 1762 5592School of Journalism and Communication, Hua Qiao University, School of Film and Communication, Xiamen University of Technology, Department of Economic and Management, Suzhou Vocational Institute of Industrial Technology, Xiamen, 361021 China ,grid.145695.a0000 0004 1798 0922Director of Business Analytics Research Center, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Hao Chen
- grid.495500.d0000 0004 1762 5592School of Journalism and Communication, Hua Qiao University, School of Film and Communication, Xiamen University of Technology, Department of Economic and Management, Suzhou Vocational Institute of Industrial Technology, Xiamen, 361021 China ,grid.145695.a0000 0004 1798 0922Director of Business Analytics Research Center, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Fang Zhou
- grid.495500.d0000 0004 1762 5592School of Journalism and Communication, Hua Qiao University, School of Film and Communication, Xiamen University of Technology, Department of Economic and Management, Suzhou Vocational Institute of Industrial Technology, Xiamen, 361021 China
| | - Qiqi Long
- grid.8547.e0000 0001 0125 2443Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200090 China
| | - Kan Wu
- grid.145695.a0000 0004 1798 0922Director of Business Analytics Research Center, Chang Gung University, Taoyuan, 33302 Taiwan ,grid.413801.f0000 0001 0711 0593Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, 33302 Taiwan
| | - Liang-Ming Lo
- grid.145695.a0000 0004 1798 0922Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taipei, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Tai-Ho Hung
- grid.145695.a0000 0004 1798 0922Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taipei, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chia-Yih Liu
- grid.413801.f0000 0001 0711 0593Department of Psychiatry, Chang Gung Memorial Hospital, Taipei, 10507 Taiwan
| | - Wen-Ko Chiou
- grid.413801.f0000 0001 0711 0593Department of Psychiatry, Chang Gung Memorial Hospital, Taipei, 10507 Taiwan ,grid.145695.a0000 0004 1798 0922Department of Industrial Design, Chang Gung University, Taoyuan, 33302 Taiwan ,grid.440372.60000 0004 1798 0973Department of Industrial Engineering and Management, Ming Chi University of Technology, New Taipei, 24301 Taiwan
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Abstract
Objectives The present study investigated the effectiveness of an 8-week mindfulness mobile phone app on women’s depression, anxiety, stress and mindful attention/awareness in the postnatal period. Methods The study enrolled 99 mothers of a child under 1 year old, and randomly assigned them to intervention (n = 49, mean age = 31.11, SD = 4.30, years) and control (n = 50, mean age = 31.35, SD = 5.29, years) groups. Multiple regression examined intervention effects on depression, anxiety, stress and mindful attention/awareness measured post-intervention and at 4-week follow-up, controlling for the baseline and post-intervention measurement of the specific outcome, respectively. Results The intervention group showed significant decreases in depression, anxiety and stress levels and an increase of mindful attention/awareness post-intervention compared to the control group, with medium to large effect sizes after controlling for effects of corresponding variables at baseline. The intervention group showed further decrease in depression and stress levels and an increase in mindful attention/awareness at 4 weeks post-intervention compared to the control group, with small to medium effect sizes, after controlling for effects of corresponding variables at post-intervention. Conclusions The outcomes of the study suggest that delivery of mindfulness via smartphones could be a viable and affordable resource for reducing postnatal depression, anxiety and stress.
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Affiliation(s)
- Katie A Bear
- School of Psychology, University of Waikato, Hillcrest, Private Bag 3105, 3240 Hamilton, New Zealand
| | - Carol C Barber
- School of Psychology, University of Waikato, Hillcrest, Private Bag 3105, 3240 Hamilton, New Zealand
| | - Oleg N Medvedev
- School of Psychology, University of Waikato, Hillcrest, Private Bag 3105, 3240 Hamilton, New Zealand
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Sadeghi-Bahmani D, Esmaeili L, Mokhtari F, Sadeghi L, Afsharzadeh M, Shaygannejad V, Mirmosayyeb O, Goldstein-Piekarski AN, Gross JJ. Effects of Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction (MBSR) on Symptoms and Emotional Competencies in Individuals with Multiple Sclerosis. Mult Scler Relat Disord 2022; 67:104029. [DOI: 10.1016/j.msard.2022.104029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 10/31/2022]
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Reangsing C, Lauderman C, Schneider JK. Effects of Mindfulness Meditation Intervention on Depressive Symptoms in Emerging Adults: A Systematic Review and Meta-Analysis. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:6-24. [PMID: 35085023 DOI: 10.1089/jicm.2021.0036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Depression in emerging adults (20-29 years of age), a transition from adolescence to adulthood, is a mental health problem globally. Antidepressants and psychotherapy have limited effectiveness and might not be available worldwide. Alternative and complementary treatments, such as mindfulness meditation, are growing. Objective: We examined the effects of mindfulness interventions on depression in emerging adults and explored the moderating effects of participants, methods, and intervention characteristics. Design: Systematic review and meta-analysis. Subjects: Emerging adults. Interventions: Mindfulness meditation interventions versus control groups. Outcomes measures: depressive symptoms. Results: Forty-five studies resulted in 49 comparisons, including 3479 participants (23.0-2.7 years old); 1826 participants practiced mindfulness and 1653 served as controls. Overall, mindfulness interventions showed significant reduction in depression compared with controls (g = 0.44, 95% confidence interval: 0.33-0.55). Mindfulness interventions conducted in Asian countries had a greater decrease in depression (g = 0.69) than studies conducted in North America (g = 0.44) or Europe (g = 0.23). Mindfulness interventions showed greater reductions in depression in studies with higher proportion of females (Slope = 0.010, τ2 = 0.07, Qbetween = 7.10, p = 0.008). Mindfulness interventions conducted in emerging adults with depressive disorders reduced depression more (g = 1.12) than in emerging adults without (g = 0.40). Providing mindfulness intervention in a group setting had a greater reduction of depression (g = 0.54) than on an individual basis (g = 0.30). More minutes of unstructured mindfulness practice per session showed a greater reduction in depressive symptoms (Slope = 0.016, Qbetween = 1.34, p = 0.035). Using intention-to-treat analyses showed a lower ES (g = 0.14) than not using it (g = 0.55). Other quality indicators were not significant moderators. Primary researchers did not report the adverse effects of mindfulness interventions. Conclusion: Mindfulness interventions somewhat improved depression in emerging adults. Because primary researchers did not report the adverse effects, mindfulness interventions should be used with caution. Future researchers might study the adverse effects of mindfulness interventions as well as the long-term effects.
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Affiliation(s)
- Chuntana Reangsing
- School of Nursing, Mae Fah Luang University, Muang, Chiangrai province, Thailand
| | - Christina Lauderman
- Trudy Busch Valentine School of Nursing, Saint Louis University, St. Louis, MO, USA
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11
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Zhuang CY, Lin SY, Cheng CJ, Chen XJ, Shi HL, Sun H, Zhang HY, Fu MA. Home-based nursing for improvement of quality of life and depression in patients with postpartum depression. World J Clin Cases 2020; 8:4785-4792. [PMID: 33195646 PMCID: PMC7642553 DOI: 10.12998/wjcc.v8.i20.4785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/30/2020] [Accepted: 09/04/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postpartum depression is a common mental illness in puerpera, with an incidence of approximately 3.5%-33.0% abroad, and the incidence of postpartum depression in China is higher than the international level, reaching 10.0%-38.0%. Providing effective nursing care in clinical nursing activities is one of the key points of obstetrical care. However, little research has been designed to investigate the positive role of home-based nursing in the prevention of postpartum depression .
AIM To study the effect of home-based nursing for postpartum depression patients on their quality of life and depression.
METHODS The clinical data of 92 patients with postpartum depression treated at our hospital were retrospectively analyzed. The patients were grouped according to the nursing methods used; 40 patients receiving basic nursing were included in a basic nursing group, and 52 receiving home-based nursing were included in a home-based nursing group. Depression and anxiety were evaluated and compared between the two groups. The estradiol (E2), serotonin (5-hydroxytryptamine, 5-HT), and progesterone (PRGE) levels were measured.
RESULTS The SAS and SDS scores of the home-based nursing group were significantly lower than those of the basic nursing group (P < 0.05). The E2 and 5-HT levels of the home-based nursing group were significantly higher than those of the basic nursing group, but the PRGE level was significantly lower than that of the basic nursing group. The GQOLI-74 scores (material, social, somatic, and psychological) and nursing satisfaction were significantly higher in the home-based nursing group (P < 0.05).
CONCLUSION Postpartum depression through home-based nursing can effectively alleviate depression and improve the quality of life of patients, help modulate their serum E2, 5-HT, and PRGE levels, and improve their satisfaction with nursing care.
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Affiliation(s)
- Chun-Yu Zhuang
- Department of Nursing, Haikou Maternal and Child Health Hospital, Haikou 570203, Hainan Province, China
| | - Sheng-Ying Lin
- Department of Nursing, Haikou Maternal and Child Health Hospital, Haikou 570203, Hainan Province, China
| | - Chen-Jia Cheng
- Department of Hepatobiliary Surgery, Hainan Provincial People's Hospital, Haikou 570311, Hainan Province, China
| | - Xiao-Jing Chen
- Department of Medicine, Haikou Maternal and Child Health Hospital, Haikou 570203, Hainan Province, China
| | - Hui-Ling Shi
- Department of Care Medicine, Haikou Maternal and Child Health Hospital, Haikou 570203, Hainan Province, China
| | - Hong Sun
- Department of Nursing, Haikou Maternal and Child Health Hospital, Haikou 570203, Hainan Province, China
| | - Hong-Yu Zhang
- Department of Midwifery, School of International Nursing, Hainan Medical College, Haikou 570203, Hainan Province, China
| | - Mian-Ai Fu
- Department of Reproductive Medicine, Haikou Maternal and Child Health Hospital, Haikou 570203, Hainan Province, China
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Cuijpers P, Noma H, Karyotaki E, Vinkers CH, Cipriani A, Furukawa TA. A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry 2020; 19:92-107. [PMID: 31922679 PMCID: PMC6953550 DOI: 10.1002/wps.20701] [Citation(s) in RCA: 247] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
No network meta-analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long-term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop-out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment-resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random-effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta-analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14-1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14-1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92-1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05-1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02-1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment-resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long-term effects of treatments (including cost-effectiveness), on the impact of specific pharmacological and non-pharmacological approaches, and on the effects in specific populations of patients.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical, Neuro and Developmental PsychologyAmsterdam Public Health Research Institute, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Hisashi Noma
- Department of Data ScienceInstitute of Statistical MathematicsTokyoJapan
| | - Eirini Karyotaki
- Department of Clinical, Neuro and Developmental PsychologyAmsterdam Public Health Research Institute, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Christiaan H. Vinkers
- Department of PsychiatryAmsterdam UMC (location VUmc)AmsterdamThe Netherlands,Department of Anatomy and NeurosciencesAmsterdam UMC (location VUmc)AmsterdamThe Netherlands
| | - Andrea Cipriani
- Department of Psychiatry Warneford Hospital, University of OxfordOxfordUK,Oxford Health NHS Foundation Trust, Warneford HospitalOxfordUK
| | - Toshi A. Furukawa
- Department of Health Promotion and Human BehaviorKyoto University Graduate School of Medicine, School of Public HealthKyotoJapan
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13
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Budiman MEA, Sari SNJ, Kusumawardani W, Sutopo D. Strategy Intervention to Prevent and Reduce Postpartum Depression: A Systematic Review. JURNAL NERS 2020. [DOI: 10.20473/jn.v14i3.17149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Postpartum depression is a non-psychotic depressive disorder with the criteria for diagnosis being that it can start early at four weeks postpartum. This can occur in the first year postpartum. Postpartum depression can result in deep sorrow and even the risk of suicide.Method: The sources of the articles used were from a search of the Scopus, PubMed and Proquest databases with the keywords “postpartum depression, nursing intervention, psychology and postpartum”. The search was restricted articles ranging from 2014 until 2018. After the articles were obtained, then the articles were reviewed until the stage of making a systematic review.Result: The systematic review resulted in 15 of 19 choices of interventions that can be used to prevent and reduce the symptoms of postpartum depression. The results found that an internet cognitive behavior therapy intervention is very significant in terms of preventing and reducing the symptoms of postpartum depression. Nursing interventions are packaged in a variety of programs proven to reduce the postpartum depression variables and actions needed to prevent and reduce the symptoms of postpartum depression significantly.Conclusion: Based on the results of the analysis of the 15 journals from the results of the study, internet cognitive behavior therapy intervention is recommended to prevent and reduce postpartum depression. This intervention can be developed practically and easily.
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Cooper MC, Kilvert HS, Hodgkins P, Roskell NS, Eldar-Lissai A. Using Matching-Adjusted Indirect Comparisons and Network Meta-analyses to Compare Efficacy of Brexanolone Injection with Selective Serotonin Reuptake Inhibitors for Treating Postpartum Depression. CNS Drugs 2019; 33:1039-1052. [PMID: 31642037 PMCID: PMC6825025 DOI: 10.1007/s40263-019-00672-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Brexanolone injection, the first therapy approved by the US FDA for the treatment of postpartum depression (PPD) in adults, has been shown to produce a significantly greater decrease in the Hamilton Rating Scale for Depression (HAM-D) total score than placebo in randomised controlled trials (RCTs) of women with PPD. OBJECTIVES Given the rapid effect of brexanolone injection (within 60 h) sustained throughout the length of the trials (30 days), we sought to compare its efficacy data against selective serotonin reuptake inhibitors (SSRIs), the class of antidepressants most commonly prescribed for PPD, using HAM-D and Edinburgh Postnatal Depression Scale (EPDS) outcomes from currently available RCTs. METHODS We extracted data from 26 studies identified in a systematic literature review of pharmacological and pharmacological/nonpharmacological combination therapies in PPD. Six studies were suitable to form evidence networks through which to perform indirect treatment comparisons (ITCs) of HAM-D and EPDS outcomes between brexanolone and SSRIs. Having assessed the comparability and suitability of the available evidence for analysis, we discovered significant heterogeneity in the study designs, most notably in the placebo arms of the trials. We therefore conducted matching-adjusted indirect comparisons (MAICs) between brexanolone and the placebo arms of comparator studies, subsequently using the MAIC results of brexanolone versus placebo, and results for SSRIs versus placebo, to form ITCs of brexanolone versus SSRIs at three separate time points-day 3, week 4 and last observation. ITCs were calculated as the differences in change from baseline (CFB) in HAM-D and, separately, CFB in EPDS, between treatments, and reported with 95% confidence intervals (CIs). RESULTS For all time points, MAICs showed larger differences in CFB for brexanolone compared with SSRIs. Differences (95% CIs) between brexanolone and SSRIs were 12.79 (8.04-17.53) [day 3], 5.87 (- 1.62 to 13.37) [week 4] and 0.97 (- 6.35 to 8.30) [last observation] for the HAM-D. For the EPDS, the differences in CFB were 7.98 (5.32-10.64) [day 3], 6.35 (3.13-9.57) [week 4] and 4.05 (0.79-7.31) [last observation]. Other analytical approaches are also presented to demonstrate the similarity of results, using a network meta-analysis approach, and the importance of using the MAIC method to control for the important heterogeneity between placebo arms. CONCLUSIONS Acknowledging the limitations of ITCs and this evidence base, when compared with SSRIs, these analyses suggest that brexanolone demonstrated larger differences in CFB for both patient- and clinician-reported PPD outcomes and at all investigated time points after adjusting for differences between placebos in the included studies.
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15
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Bottaccioli AG, Bottaccioli F, Minelli A. Stress and the psyche-brain-immune network in psychiatric diseases based on psychoneuroendocrineimmunology: a concise review. Ann N Y Acad Sci 2018; 1437:31-42. [PMID: 29762862 DOI: 10.1111/nyas.13728] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022]
Abstract
In the last decades, psychoneuroendocrineimmunology research has made relevant contributions to the fields of neuroscience, psychobiology, epigenetics, molecular biology, and clinical research by studying the effect of stress on human health and highlighting the close interrelations between psyche, brain, and bodily systems. It is now well recognized that chronic stress can alter the physiological cross-talk between brain and biological systems, leading to long-lasting maladaptive effects (allostatic overload) on the nervous, immune, endocrine, and metabolic systems, which compromises stress resiliency and health. Stressful conditions in early life have been associated with profound alterations in cortical and subcortical brain regions involved in emotion regulation and the salience network, showing relevant overlap with different psychiatric conditions. This paper provides a summary of the available literature concerning the notable effects of stress on the brain and immune system. We highlight the role of epigenetics as a mechanistic pathway mediating the influences of the social and physical environment on brain structure and connectivity, the immune system, and psycho-physical health in psychiatric diseases. We also summarize the evidence regarding the effects of stress management techniques (mainly psychotherapy and meditation practice) on clinical outcomes, brain neurocircuitry, and immune-inflammatory network in major psychiatric diseases.
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Affiliation(s)
- Anna Giulia Bottaccioli
- Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche, Università degli Studi di Roma La Sapienza, Internal Medicine Unit, ICOT Hospital, Latina, Italy
| | - Francesco Bottaccioli
- Dipartimento di Medicina Clinica, Università degli Studi dell'Aquila, Sanita Pubblica Scienze della Vita e dell'Ambiente, L'Aquila, Italy
| | - Andrea Minelli
- Dipartimento di Scienze Biomolecolari, Università degli Studi di Urbino Carlo Bo, Urbino, Italy
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16
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Ahmadpanah M, Akbari T, Akhondi A, Haghighi M, Jahangard L, Sadeghi Bahmani D, Bajoghli H, Holsboer-Trachsler E, Brand S. Detached mindfulness reduced both depression and anxiety in elderly women with major depressive disorders. Psychiatry Res 2017; 257:87-94. [PMID: 28735173 DOI: 10.1016/j.psychres.2017.07.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 07/04/2017] [Accepted: 07/14/2017] [Indexed: 11/28/2022]
Abstract
We investigated the influence of detached mindfulness (DM) in treating symptoms of depression and anxiety among elderly women. Thirty-four elderly females (mean age: 69.23 years) suffering from moderate major depressive disorders (MDD) and treated with a standard medication (citalopram) at therapeutic doses were randomly assigned either to an intervention condition (DM; group treatment, twice weekly) or to a control condition (with leisure activities, twice weekly). At baseline (BL), four weeks later at study completion (SC), and four weeks after that at follow-up (FU), participants completed ratings for symptoms of depression and anxiety; experts blind to patients' group assignments rated patients' symptoms of depression. Symptoms of depression (self and experts' ratings) and anxiety declined significantly over time in the DM, but not in the control condition. Effects remained stable at FU. The pattern of results suggests that, compared to a control condition, a specific psychotherapeutic intervention such as DM can have a beneficial effect in elderly female patients with MDD.
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Affiliation(s)
- Mohammad Ahmadpanah
- Behavioral Disorders and Substances Abuse Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Amineh Akhondi
- Hamadan Educational Organization, Ministry of Education. Hamadan, Iran
| | - Mohammad Haghighi
- Behavioral Disorders and Substances Abuse Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Leila Jahangard
- Behavioral Disorders and Substances Abuse Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Dena Sadeghi Bahmani
- Psychiatric Clinics of the University of Basel, Center for Affective, Stress und Sleep Disorders, University of Basel, Basel, Switzerland
| | - Hafez Bajoghli
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Edith Holsboer-Trachsler
- Psychiatric Clinics of the University of Basel, Center for Affective, Stress und Sleep Disorders, University of Basel, Basel, Switzerland
| | - Serge Brand
- Psychiatric Clinics of the University of Basel, Center for Affective, Stress und Sleep Disorders, University of Basel, Basel, Switzerland; Department of Sport, Exercise and Health, Division of Sport and Psychosocial Health, University of Basel, Basel, Switzerland; Sleep Disorders Research Center, Kermanshah University of Medical Sciences (KUMS), Kermanshah, Iran.
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