Mindfulness-based interventions during the COVID-19 pandemic: a focused review

The coronavirus disease 2019 (COVID-19) pandemic has raised alarm all over the world, whereby the mental health crisis is on the rise and people are in quest for resolution. So, the present review paper is an attempt to evaluate the previous work on mindfulness, and, its impact during the COVID-19 pandemic . Mindfulness as a multidimensional construct teaches us to regulate our awareness of the present moment followed by an attitude of non-judgemental acceptance. This paradigm shift (cid:76)(cid:81)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:191)(cid:72)(cid:79)(cid:71)(cid:3)(cid:82)(cid:73)(cid:3)(cid:83)(cid:86)(cid:92)(cid:70)(cid:75)(cid:82)(cid:79)(cid:82)(cid:74)(cid:92)(cid:3)(cid:75)(cid:68)(cid:86)(cid:3)(cid:70)(cid:85)(cid:72)(cid:68)(cid:87)(cid:72)(cid:71)(cid:3)(cid:90)(cid:82)(cid:81)(cid:71)(cid:72)(cid:85)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:83)(cid:86)(cid:92)(cid:70)(cid:75)(cid:82)(cid:87)(cid:75)(cid:72)(cid:85)(cid:68)(cid:83)(cid:72)(cid:88)(cid:87)(cid:76)(cid:70)(cid:3)(cid:83)(cid:85)(cid:68)(cid:70)(cid:87)(cid:76)(cid:70)(cid:72)(cid:17)(cid:3)(cid:55)(cid:75)(cid:72)(cid:3)(cid:70)(cid:88)(cid:85)(cid:85)(cid:72)(cid:81)(cid:87)(cid:3)(cid:85)(cid:72)(cid:89)(cid:76)(cid:72)(cid:90)(cid:3)(cid:68)(cid:76)(cid:80)(cid:86)(cid:3)(cid:87)(cid:82)(cid:3)(cid:75)(cid:76)(cid:74)(cid:75)(cid:79)(cid:76)(cid:74)(cid:75)(cid:87)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:181)(cid:90)(cid:75)(cid:92)(cid:182)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:181)(cid:75)(cid:82)(cid:90)(cid:182)(cid:3)(cid:82)(cid:73)(cid:3)(cid:80)(cid:76)(cid:81)(cid:71)(cid:73)(cid:88)(cid:79)(cid:81)(cid:72)(cid:86)(cid:86)(cid:3)(cid:68)(cid:86)(cid:3)(cid:76)(cid:81)(cid:87)(cid:72)(cid:85)(cid:89)(cid:72)(cid:81)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:87)(cid:75)(cid:68)(cid:87)(cid:3)(cid:70)(cid:82)(cid:88)(cid:79)(cid:71)(cid:3)(cid:85)(cid:72)(cid:68)(cid:70)(cid:75)(cid:3)(cid:72)(cid:89)(cid:72)(cid:85)(cid:92)(cid:3)(cid:83)(cid:72)(cid:85)(cid:86)(cid:82)(cid:81)(cid:15)(cid:3)(cid:69)(cid:72)(cid:3)(cid:76)(cid:87)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:38)(cid:50)(cid:57)(cid:44)(cid:39)(cid:16)(cid:20)(cid:28)(cid:3)(cid:86)(cid:88)(cid:4231)(cid:72)(cid:85)(cid:72)(cid:85)(cid:86)(cid:3)(cid:82)(cid:85)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:38)(cid:50)(cid:57)(cid:44)(cid:39)(cid:16)(cid:20)(cid:28)(cid:3)(cid:90)(cid:68)(cid:85)(cid:85)(cid:76)(cid:82)(cid:85)(cid:86)(cid:17)(cid:3) in adjunct to other psychotherapeutic treatments. Therefore, it calls forth the need to put mindfulness-based interventions during this pandemic situation.


INTRODUCTION
e current coronavirus disease 2019 (COVID-19) pandemic, declared by the World Health Organization (WHO) on the 11th of March 2020 has global impact that has shaken the healthcare system worldwide. [1] e government has been trying various measures to reduce the impact starting from isolation, social distancing, lockdown, and quarantine. e pandemic has not only affected the physical health of persons, but, has gross manifestations in the psychological health too. Many studies have documented that this pandemic has been associated with depression, anxiety, trauma, loneliness, sleep disturbances, and other psychological issues. [2] ere have been various social factors like job losses, economic deprivation, migration to the homeland, stigma, and other psychosocial factors that have significantly created additional stress to the population resulting in higher rates of suicide. In an article by Dsouza et al., [3] the causal factors associated with suicide in India was documented; which ranged from the fear of getting infected with COVID-19, financial crisis, loneliness, stigma associated to quarantine, work-related stress, not being able to return home, due to the postponement of examinations, etc. e pandemic has not only affected the general population, but also the healthcare workers who are at the forefront of this battle. e workload has resulted in "burnout, distress, and emotional suffering".[4] With the rise in mental health issues, the psychological services have great demand, with mindfulness as one such practice. e Buddhist traditions used to and even now have been nourishing the concept of mindfulness as a practice that leads to the cessation of mental suffering. [5] Mindfulness practice is more than just meditation and involves one's conscious attention to moment-to-moment experiences. [6] e concept started gaining popularity with its significance in various psychotherapies. [7] With the advent of this concept in psychotherapy, many researchers have started exploring the mechanisms involved and its efficacy, with the majority of the studies suggesting a positive outcome. Mindfulness practice has been used effectively as an adjunct with other forms of therapies like acceptance commitment therapy (ACT), [8] dialectical behavioural therapy (DBT), [9] mindfulness-based stress reduction therapy (MBSR), [10] and mindfulness-based cognitive therapy (MBCT). [11] Literature on the mindfulness-based therapies indicated significant improvement in patients with different medical conditions such as cancer, [12,13] diabetes,[14] human immunodeficiency virus (HIV), [15] and chronic pain. [16] Recent studies have found that mindfulness-based treatment is quite effective in reducing the symptoms related to anxiety and mood disorders, [17,18] in treating obesity, and other eating disorders such as binge eating, [19] and in reducing the relapse rates in patients with substance abuse. [20,21] e psychological mechanisms underlying the mindfulnessbased therapies have been explained through various models like the intention-attention-attitude (IAA) model by Shapiro et al., [22] Buddhist psychological model (BPM) by Grabovac et al., [23] and the monitor and acceptance theory (MAT) based on the empirical work of Lindsay and Creswell. [24] As mindfulness-based interventions are gaining popularity in the field of health, researchers are keen on understanding the neurobiological mechanisms that help mindfulness interventions to succeed. Tang et al. [25] used integrative

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mind-body training (IMBT), one form of mindfulnessbased intervention. rough randomised controlled trials, they found that executive functioning improved with the underlying role of the autonomic nervous system and anterior cingulate cortex in IMBT. During this pandemic, whereby the mental health crisis is on the rise, mindfulness can be looked upon as an essential therapeutic technique that can heal psychological wounds.
e current review will, therefore, aim to highlight the 'why' and 'how' of mindfulness as an intervention that could reach every person, be it the COVID-19 sufferers or the COVID-19 warriors.

IMPORTANCE OF MINDFULNESS-BASED INTERVENTIONS DURING COVID-19 PANDEMIC
With the rise of this pandemic situation, human beings are struggling over fulfilling basic needs with feelings of helplessness and hopelessness predominating over the meaning of life. Mindfulness-based strategies can be effective in this pandemic by building distress tolerance, helping people regain a sense of meaning in their lives, and help develop relational depth in interpersonal relationships. Recent literature has been highlighting mindfulness as an important way of coping with this pandemic. Polizzi et al. [26] highlighted the importance of mindfulness practice in everyday lives by aiming at bare-awareness into the current moment, learning that a "thought is just a thought" or that uncertainties are momentary and can be replaced by alternative thought or feeling, thereby increasing resilience. Besides reviewing the importance of such interventions, few researchers tried experimenting on the efficacy of mindfulness-based practices during this pandemic. Few studies have also documented the efficacy of online interventions, particularly mindfulness practice. [27] Few presentations of those studies are described in Table 1.
From the literature presented in this manuscript which highlight the importance of mindfulness-based interventions, it can be said that the current pandemic scenario in our country will require more evidence-based studies, on different workplace settings, and especially for the healthcare workers, who are at the forefront of this battle. Work-site interventions and modules are required for mindfulnessbased interventions, with more empirical evidence based on randomised controlled trials or case reports.

LIMITATIONS
e articles for this review were taken from Google Scholar and PubMed, and therefore might have omitted other relevant articles from other electronic databases like PsycINFO, Cochrane, etc. Also, most of the articles were review-based which highlighted the requirement of mindfulness, with very few articles to empirically prove it during the current scenario.
erefore, the reviews were very limited, a few proposing manuals or protocols of mindfulness that can be used during this crisis, but the efficacy is tested in only some articles. erefore, more such research is required as long as the pandemic is continuing to get better insights into the efficacy of mindfulness as an intervention.
hospital in Milan, Italy. ACT; mindfulness exercises.
-Objective is to maintain mental them work even under the highpressure conditions experienced during the COVID-19 pandemic. The programme is in its early stages and and incomplete.
Kwon et al. [31] isolated patients, and the general public complaining of anxiety related to COVID-19.
-Mindfulness meditation. Bäuerle et al. [34] above, equipped with German language, internet access, and basic computer using skills, who contact the CoPE hotlines. Social media platforms and awareness of this work.
Based on sample size estimation, 110 numbers of participants will be required to complete the study. Based on dropout rates, the researchers decided to recruit 240 participants at the baseline assessment. There are four modules, 30 minutes each. The modules are a combination of skill training followed by mindfulness intervention. There will be an initial baseline assessment followed by intervention. After intervention, there will be an immediate post-intervention assessment, and a three-month and six-month follow-up assessment. two is the test group as they were recruited when there was partial lockdown in Singapore. received mindfulness intervention during COVID-19 pandemic (in-person face to face sessions=36 participants of Group 1 and video-conferencing mode sessions=38 participants of Group 2).
The third group was tested before the pandemic. They were measured on perceived stress and sleep quality.
The courses were four or eight sessions taught by Participants were survey form after and after the last session. impact in reducing stress in all the three groups. Sleep quality was for the pre-pandemic group (i.e. group 3), but not in the other two groups. They concluded that online mindfulness interventions have a profound impact in reducing the perception of stress, but no such improvement is evident in sleep during the pandemic.

Intervention intervention
El Morr et al. [27] Undergraduate students of a Canadian university who were 18 years of age and above. Students involved in substance abuse and past history of psychosis were excluded from the study.
Total sample size was 160, with 80 in each group. It was an RCT study where one group received mindfulness-based training and the other was a control group of university students. The mindfulness-based training was a web-based programme called as MVC. Participants were measured on the domains of depression, anxiety, stress, and mindfulness.
It was an eightweek intervention programme delivered online through videos, discussion forums, and videoconferences. in the symptoms of depression and anxiety, but not in perceived stress, mindfulness among the university students who received MVC as compared to the control group.
Reyes [37] Healthcare workers and patients who are recovering from COVID-19 crises. - The research is ongoing to explore intervention which was proposed by Alexopoulos et al. [38] The spread of COVID-19 among various populations and need for the mental health services which are nonstigmatised. So, looking at the need also reveal that mindfulness-based mobile app intervention shows much veterans with PTSD. [37] Therefore, looking at the above evidence, the mobile app intervention will also bring the same promising result among the former healthcare professionals and the patient recovering from COVID-19.
Wei et al. [39] The study was conducted Hangzhou, China on the 19 in the isolation ward, aged between 18-65 years.
Twenty six patients enrolled themselves for the study. There were two groups: 13 patients received the internet-based integrated intervention and the rest 13 patients were kept as a control group who received daily supportive care. In internet-based integrated intervention, clients received audio recordings focused on four skills: relaxation training, body scan technique of mindfulness, "refuge" skills, and measured on the scales of depression and anxiety pre and post intervention.
It was a twoweek intervention programme where audio-based instructions were given for each day for two weeks from February 2 to February 28, 2020. It was found that there was a of depression and anxiety when compared to the control group interventions in the patients diagnosed with COVID-19. CONCLUSION e present review gives an insight into the efficacy of mindfulness as an intervention itself or as an effective adjunct to other psychotherapeutic treatments. It also highlights the importance and the need for it during this current pandemic crisis. ese practices have also proven to be efficacious in online mode, and therefore, can be incorporated in tele-mental health services. It is cost-effective and also minimises the risk of corona virus spread. However, this review has mostly been limited to review work with a few evidence-based practices. erefore, it calls forth the need to put mindfulness-based interventions during this pandemic situation by integrating it into the already popular tele-mental health services, which have been demonstrated to be possible, with adequate training of mental health professionals. [41] In the future, even a er the pandemic gets resolved, the tele-mental health services can remain to be a promising mode of communication.

Intervention intervention
Lai et al. [40] long-term care home, who have participated in caring of COVID-19 patients in London, Ontario, Canada.
Sixty participants will be selected randomly after signing the consent form. The sample size of the study will be divided into 1:1 ratio for SKY and HEP. The study used the online model of SKY and HEP. The intervention of SKY will focusing on breathing control techniques for four to ten minutes each. In the second phase of the intervention, there will be one-hour interactive online session teacher. The participants will be learning and practicing about fast, medium, and slow breath. HEP will be conducted in a similar way via an online method. In self-paced modules will be given to the participants. Whereas, in the second phase of intervention, the mindfulnessbased meditation will be conducted by the mental health professionals.
According to the status of the study. The recruitment of the participants has already started from June 25, 2020 and the recruitment procedure will be completed by June 30, 2021. The overall study will be completed within September 30, 2021. The present study is on the trial and will be completed by September 30, 2021. The outcome of the study will be helpful for further investigation to intervention of SKY and HEP will be and helps in improving insomnia, anxiety, depression, and resilience participated in managing the COVID-19 patients.