Complementary Therapies in Clinical Practice 25 (2016) 59e67

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Mindfulness based stress reduction adapted for depressed

disadvantaged women in an urban Federally Qualied Health Center
Inger E. Burnett-Zeigler a, *, Maureen D. Satyshur a, Sunghyun Hong a, Amy Yang a,
Judith T. Moskowitz b, Katherine L. Wisner a
a
Northwestern University, Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL, USA
b
Northwestern University, Feinberg School of Medicine, Medical Social Sciences, Chicago, IL, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: In this study we examine the feasibility and preliminary effectiveness of mindfulness based
Received 21 June 2016 stress reduction adapted for delivery in an urban Federally Qualied Health Center (FQHC).
Accepted 12 August 2016 Methods: Thirty-one African- American adult women ages 18e65 with depressive symptoms enrolled to
participate in an 8-week mindfulness group intervention. The primary outcome (depression) and sec-
Keywords: ondary outcomes (stress, mindfulness, functioning, well-being, and depression stigma) were assessed at
Mindfulness
baseline, 8 and 16-weeks.
Mental health
Results: Depressive symptoms signicantly decreased from baseline to 16 weeks. A signicant decrease
Depression
Disadvantaged
in stress and signicant increase in mindfulness was found from baseline to 8 weeks and baseline to 16
Race/ethnicity weeks. Additionally, aspects of well-beingdself-acceptance and growthdsignicantly increased from
Women baseline to 8-weeks. Stigma signicantly increased from baseline to 8 weeks and signicantly decreased
from 8 to 16 weeks (all p's < 0.05).
Conclusions: Mindfulness-based interventions implemented in FQHCs may increase access to effective
treatments for mental health symptoms.
2016 Elsevier Ltd. All rights reserved.

1. Introduction treatment [17,48,51] and less likely to receive treatment

Depressive disorders are among the most common psychiatric
disorders with 12-month prevalence estimates ranging from 5 to
10% for Major Depressive Disorder (MDD) [30,31,38,39,41,59] and
2e5% for Dysthymic Disorder (DYS) [39,41,59]. Women [38,41] and
disadvantaged individuals such as those who are unemployed, with
less education and income, and public or no insurance are at
increased risk for having had a depressive episode in the last year
[30,31,38,41]. An estimated 40e60% of individuals with depressive
disorders do not receive treatment [30,38,78]. The disparity be-
tween individuals with psychiatric needs versus those receiving
treatment is in part attributable to negative attitudes toward
traditional mental health treatment, concerns about stigma and
embarrassment [25,28,51] and mistrust of the mental health sys-
tem [51]. Disadvantaged individuals are more likely to hold stig-
matizing beliefs and negative attitudes toward mental health
* Corresponding author. 676 N. St. Claire, Suite 1000, Chicago, IL, 60611, USA.
E-mail address: i-burnett-zeigler@northwestern.edu (I.E. Burnett-Zeigler).
[40,46,53,78].
The majority of those who do receive depression treatment
receive it in primary care, rather than specialty mental health
clinics [38,40,42,78]. In primary care, antidepressants are the most
commonly offered depression treatments, however adherence is
poor (40%e75%) [54], the response rate (60%) is low [76], many do
not consider antidepressants acceptable treatments (Lisa A [19]. or
prefer to be treated without medication [22,24,29,58,77]. Studies
on treatment preferences for depressed primary care patients have
found that 33e80% of respondents report concern about the un-
desirable side effects of medication and addiction [77]. African-
Americans and Hispanics are less likely than Whites to nd anti-
depressants acceptable and more likely to hold negative beliefs
about antidepressants (Lisa A [19,24]. Depression treatment co-
located in primary care settings likely facilitates greater access to
care for those who are unlikely to go to specialty mental health.
However, offering patients treatments that are inconsistent with
their preferences is associated with failure to initiate treatment,
poor adherence and early discontinuation [2].
Mind body (MB) complementary and integrative approaches

http://dx.doi.org/10.1016/j.ctcp.2016.08.007
1744-3881/ 2016 Elsevier Ltd. All rights reserved.
60 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67
(CIA) such as meditation (including mindfulness), movement
therapies, relaxation (breathing exercises, guided imagery, pro-
gressive muscle relaxation) and yoga are among the most
commonly used CIAs and they continue to increase in their popu-
larity [9]. Despite overall lower rates of using MB approaches
among racial/ethnic minorities (14.8% African-American versus
21.4% White) [9], signicant proportions of racial/ethnic minorities
use CIAs as health treatments [7,8,10,11,49] found that 69% of Af-
rican Americans in the general population used CIAs (including
prayer) in the last 12 months [7,8]. A study of underserved African-
American and Hispanic patients in primary care found that 24e33%
reported using CIAs for the treatment of depression; of those that
used CIAs, 47% used MB approaches. In this study, patients without
health insurance, moderate depression, using psychiatric medica-
tion and poorer self-reported health status were more likely to use
CIAs [10].
Mind body approaches to depression treatment co-located in
primary care may be more accessible and acceptable than con-
ventional mental health treatments among disadvantaged in-
dividuals [4,7,8,10,72,79] suggests that individuals who believe in
the importance of body, mind and spirit in treating health prob-
lems are more likely to use alternative medicine [4]. African-
Americans report spiritual beliefs and practices are an important
part of coping with illness [18,34] and believe in the power of
spirituality to promote healing [34]. In the 2002 National Health
Interview Survey, 67% of African-Americans reported using prayer
for their own health [26]. It is likely that mind body approaches to
healthcare are culturally synergistic with the worldview of
African-Americans who already incorporate spiritualty into coping
with and treating illness [4]. also found that those who distrust
conventional physicians and desire control over their own health
are more likely to rely on alternative forms of medicine [4].
African-Americans report higher levels of medical mistrust than
other race/ethnicities [14]. Additionally, African-Americans who
report more instances of racial discrimination in medical and non-
medical settings are more likely to use CIAs [68]. African-
Americans may perceive alternative health approaches that can
be employed independent of medical professionals as more
acceptable than conventional medicine. Finally, individuals who
experience problems accessing healthcare [37] or nd conven-
tional healthcare is too expensive [9,26,52,74] are more likely to
use CIAs.
Mindfulness meditation involves intentionally paying sustained
attention to ongoing sensory, cognitive and emotional experiences
without elaborating or judging any part of that experience [35].
Mindfulness based interventions have collectively been shown to
improve physical and mental health [5,43,55] and have at least
medium-sized effects (Cohen's d 0.5e0.6) [5,27,33,43]. Few
studies have examined the effectiveness of mindfulness based in-
terventions among disadvantaged populations. A meta-analysis of
acceptance and mindfulness based interventions with underserved
populations (N 35) found small to large effect sizes (Hedges' g
range 0.38e1.32). Studies that included no-contact or waitlist
condition demonstrated the largest effect size (g 1.32), followed
by studies that used an active treatment (g 0.67) and studies
using a pre-post design (g 0.57). Of the 35 studies reviewed, 8
evaluated MBSR or MBCT and 5 of those 8 studies were with
disadvantaged populations (racial/ethnic minority, urban youth,
forensic). In 3 of the 5 studies, participation in a mindfulness based
intervention was associated with signicant pre-post changes in
reported psychological outcomes [23]. This review highlights the
paucity of research examining the effectiveness of mindfulness
based interventions among disadvantaged, racial/ethnic minority
adult populations.
One of the most widely used mindfulness based interventions
is Mindfulness Based Stress Reduction (MBSR), an 8-week group
intervention that teaches mindfulness skills through a range of
formal and informal mindfulness practices including mindfulness
of breath, bodily sensations, sounds, thoughts and everyday ac-
tivities. The few studies that have been conducted about use of
MBSR among disadvantaged individuals report program
completion rates higher than those of other evidence based
treatments [21,32,61]. Additionally, participants believe the skills
they acquire are important, they are willing to practice MBSR
techniques on their own, even after the intervention ends and
they state that mindfulness became an integral part of their lives
[12,21,61]. Preliminary research suggests that mindfulness based
interventions are efcacious in reducing mental health symptoms
[1,13,67,70,71] and improving general health [45,57,60e62], daily
functioning, interpersonal relationships and overall quality of life
among disadvantaged individuals [12,21,32,47,69e71].
Mindfulness based interventions provided within primary care
may be an important depression treatment alternative for in-
dividuals of lower socioeconomic status and racial/ethnic minor-
ities who are less likely to access conventional mental health
treatment. Mind body approaches are utilized among disadvan-
taged populations and use of these interventions is associated with
positive psychological outcomes. However, little is known about
the effectiveness of mindfulness based interventions among
disadvantaged, racial/ethnic minority populations in the primary
care setting. The aims of the present study were to: 1) Evaluate
feasibility of recruitment, enrollment and retention in a mindful-
ness based intervention for depression delivered to disadvantaged
women in a FQHC and 2) Generate preliminary data on the distri-
bution and variability of the primary outcome, depression and
secondary outcomes mindfulness, stress, functioning and well-
being. The limited literature suggests that participation in a
mindfulness based intervention is likely to affect these outcomes.
The overarching hypotheses are 1) Rates of enrollment and
completion will be greater than those reported in the literature for
conventional mental health treatments; (2) Participation in the
intervention will be associated with increased mindfulness, well-
being and functioning and decreased depression and stress. We
believe that participation in a mindfulness based intervention is
likely less stigmatizing than participation in a conventional mental
health treatment. Therefore, we will also assess change in depres-
sion stigma as a secondary outcome.
2. Methods
2.1. Setting and study population
Adult women were recruited from the Near North Health Ser-
vices Corporation (NNHSC) Clinic, a group of Federally Qualied
Health Centers (FQHCs) in Chicago. The NNHSC consortium in-
cludes nine clinics that have approximately 46,130 patient visits per
year; the majority are uninsured (58.86%) and living at or below the
poverty line (74%). The study was discussed with all of the NNHSC
healthcare providers. The study was also advertised via brochures
and posters in the clinic. Brochures and posters listed symptoms
including feeling stressed, overwhelmed, irritable, difculty
concentrating, unmotivated, tense, tired or fatigued that helped
potential participants identify themselves as potentially eligible.
The healthcare providers provided a brief overview of the study and
gave a brochure to all female patients between 18 and 65 years of
age who presented with depressive symptoms during a regular
healthcare visit. Potential participants were also recruited by the PI
or RA from the waiting room or self-referred.
 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67
2.2. Screening and eligibility
The PI or RA contacted all referrals in person or by phone.
Potential participants were provided an overview of the study,
rights and risks of participation and verbal consent for screening
was obtained. Referrals were screened using the Quick Inventory
of Depressive Symptomatology-Clinician Rated (QIDS-C) [65] or
Inventory of Depressive Symptomatology-Clinician Rated (IDS-C)
[63]. Women between ages 18e65, English Speaking and who
scored in the mild-severe range of depression (QIDS-C 6e24,
IDS-C 12e59) were eligible for participation in the study.
Women with present or recent (past 30-day) suicidal ideation or
attempt or current, regular practice of meditation or yoga (1
per week) were excluded from participation. The intervention
was limited to women in order to create a more homogenous
group dynamic and to foster an environment where participants
would feel comfortable discussing issues related to stress.
2.3. Study design
Eligible referrals were offered the opportunity to participate
in an adapted MBSR group intervention (M-Body) that met
weekly for 8-weeks, 90 min per session. Eligible participants
provided written consent for participation at baseline. Enrolled
participants completed assessments on the primary outcome
depression and secondary outcomes, stress, functioning, well-
being, mindfulness and depression stigma at baseline, post-
intervention (8-weeks) and follow-up (16-weeks). All assess-
ments were conducted in person, researcher guided, at the FQHC
and took approximately 90 min to complete. Participants
received reimbursement for public transportation for all study
visits. Participants received a $25 gift card for completing the 8
week assessment and a $50 gift card for completing the 16 week
assessments. The study protocol was approved by the North-
western University IRB.
2.4. M-body group
The M-Body group was led by the primary author, a licensed
clinical psychologist with training and experience in delivering
mindfulness based interventions. M-Body is adapted from the
established evidence-based MBSR program to t the FQHC
setting and patient population. M-Body maintains all of the core
components of MBSR including didactics and formal mindfulness
practices including sitting meditation, body scan and yoga. The
weekly didactics covered the following topics: simple awareness,
attention and perception, dealing with thoughts, stress causes
and physiological responses, responding versus reacting, mindful
communication, self-compassion, and developing a personal
mindfulness practice. The course curriculum included a manual
and audio CD. M-Body differs from MBSR in that the sessions
were 90 rather than 150 min per week, it does not include an
orientation session or retreat and the surface content (images
and poetry) was modied to be culturally relevant. Each session
included check-in, didactic, skill practice, inquiry and review of
homework.
Each week, participants were asked to engage in daily formal
and informal mindfulness practices. Participants were instructed
to do a formal practice at least once per day; the guidelines on
recommended minutes of practice per day varied each week.
Formal practices included sitting meditations (7, 15, and 40 min),
body scan (45 min) and yoga (~15 min). Participants were
instructed to use the audio CD to guide them through the sitting
meditations and body scan. Informal practices included inte-
grating mindfulness into daily activities, noticing pleasant and
61
unpleasant events, practicing pausing and slowing down and
mindful communication. Participants recorded the type and mi-
nutes of formal practice they completed and turned it into the
group leader each week. Participants also recorded their informal
practice on worksheets and turned it into the group leader
weekly.
The pilot study included two 8-week M-Body groups.
2.5. Measures
2.5.1. Screening
The Patient Health Questionnaire-2 (PHQ-2) is a 2-item self-
report questionnaire, rated on a 0e3 point scale, which assesses
the two essential symptoms of major depressive disorder: anhe-
donia and depressed mood. The NNHSC staff routinely screen for
depression during regular healthcare visits using the PHQ-2. In-
dividuals who scored 3 were referred to contact the M-Body
research staff. Scores of 3 or greater are considered signicantly
sensitive and specic to use as a cutoff score for major depressive
disorder (likelihood ratio 2.92) [44].
2.5.2. Eligibility
The Quick Inventory of Depressive Symptomatology (QIDS-C) is a
16-item clinician-rated questionnaire, rated on a 0e3 point scale,
which assesses symptoms associated with major depressive
disorder as detailed by the American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders e 4th
edition (DSM-IV) [3]. Items are summed (0e27) for each of the
nine symptom domains in the DSM-IV with higher scores indi-
cating more severe and frequent depressive symptoms during
the past week [65]. High convergent validity was found between
the QIDS-C and IDS-C (c 0.81) [73]. Women with scores of 6e24
on the QIDS-C were eligible for participation in the study.
The Inventory of Depressive Symptomatology e Clinician Rated
(IDS-C) is a 30-item clinician-rated questionnaire, rated on a 0e3
point scale, which assess all symptoms associated with major
depressive disorder as detailed by the American Psychiatric As-
sociation Diagnostic and Statistical Manual of Mental Disorders e
4th edition (DSM-IV) [3]. Twenty-eight of 30 questions are
summed; higher scores indicate more severe and frequent
depressive symptoms during the past week [63]. Women with
scores of 12e59 on the IDS-C were eligible for participation in
the study.
The IDS-C was used to determine eligibility for the rst pilot
group. Due to the lengthy administration time of the IDS-C
(30e40 min), the shorter QIDS-C (15e20 min) was used to deter-
mine eligibility for the second pilot group.
2.6. Primary outcome measures
Depressive symptoms were assessed using the Inventory of
Depressive Symptoms eSelf-Report (IDS-SR). The IDS-SR is a 30-
item self-report questionnaire, rated on a 0e3 point scale,
which assess all symptoms associated with major depressive
disorder as detailed by the American Psychiatry Association
Diagnostic and Statistical Manual of Mental Disorders e 4th
edition (DSM-IV) [3]. Higher scores indicate more severe and
frequent depressive symptoms during the past week [63]. High
convergent validity was found between the IDS-C, IDS-SR, Beck
Depression Inventory, and Hamilton Rating Scale for Depression
(all r's > 0.85) [64].
Functioning was assessed using the World Health Organization
Disability Adjustment Scale 2.0 (WHODAS). The WHODAS is a 12-
item (adapted from the 36 item version) self-report question-
naire, rated on a 0e4 point scale, which assesses an individual's
62 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67

disability level in six domains: cognitive, mobility, self-care, re- Table 1

lationships, life activities, and participation. Items are summed Demographic and socio-economic characteristics of participants in the M-Body
intervention.
(0e48) to indicate how much difculty an individual has had with
an activity in the past 30 days. The 36-item version has very high N 31 %
internal consistency and test-retest reliability (a 0.96, r 0.98) Age (range)
and the 12-item version was found to be similarly psychometrically Range 26e67
sound [75]. Mean 53.68
Marital Status
Stress was assessed using the Perceived Stress Scale (PSS). The
Single, never married 19 61.3
PSS is a 10-item self-report questionnaire, rated on a 0e4 point Married, partnered 5 16.1
scale, which assesses an individual's perception of stress during the Separated, divorced, widowed 7 22.6
past 30 days [16]. All items are summed (0e30), to indicate how Education
High school, GED or less 10 32.3
often an individual has experienced the thoughts or feelings asso-
Some college, vocational 14 45.0
ciated with stressors indicated in the past 30 days. High internal 4 year college 5 16.1
consistency has been reliably found for items on the PSS (all Master's degree 2 6.5
as > 0.84). Employment status
Well-being was assessed using the Ryff Scale of Psychological Employed full time 7 22.6
Employed part time 7 22.6
Well Being (RPWB). The RYFF is a 42-item self-report questionnaire,
Full time student 3 9.7
rated on a 1e6 point scale, which assesses individual's well-being Retired 2 6.5
in six areas: autonomy, environmental mastery, growth, positive Homemaker 1 3.2
relations, purpose in life, and self-acceptance. Items are summed to Unemployed 9 29.0
create a six subscale scores, higher scores indicating more well- Disabled 2 6.5
Personal income
being in that domain. High internal consistency has been found < $9999 9 29.0
for items on the DSSS (a > 0.86) [66]. $10,000e$19,999 10 32.3
Mindfulness was assessed using the Five Facet Mindfulness $20,000e34,999 6 19.4
Questionnaire (FFMQ). The FFMQ is a 39-item self-report ques- $35,000e$49,999 2 6.5
>$50,000 3 9.7
tionnaire, rated on a 1e5 point scale, which assesses an individual's
Refused 1 3.2
level of mindfulness in ve domains: describing, acting with Insurance
awareness, non-judging, non-reacting, and observing [6]. Items are Private 7 22.6
summed to create subscale scores and a total score indicating how Medicare 8 25.8
true the items are of their daily life. Medium to high internal con- Medicaid 11 35.5
Champus, Champva, VA, other military health 1 3.2
sistency has been found for the subscales of the FFMQ (all Other 5 16.1
as > 0.76). Chronic Health Conditions
Depression stigma was assessed using the Depression Self No 3 9.7
Stigma Scale (DSSS). The DSSS is a 32-item self-report ques- Yes 28 90.3
Hypertension 12
tionnaire, rated on a 1e7 point scale, which assesses an in-
Cholesterol 11
dividual's depression stigma in ve domains: general self-stigma, Depression 11
secrecy, public stigma, treatment stigma, stigmatizing experi- Arthritis 11
ences [36]. The DSSS includes items such as Telling someone I Osteoporosis 1
have depression is risky, Receiving treatment for depression Obesity 8
Diabetes 2
carries a social stigma and Other people with depression are COPD 2
morally weak. Items are summed to create subscale scores and a Asthma 2
total score. High internal consistency has been found for items on Past MH treatment
the DSSS (all as > 0.79) [36]. Past Year
No 27 87.1
Yes 4 12.9
2.7. Statistical analyses Individual Therapy 3
Group Therapy 2
Descriptive analyses were performed on demographic and Emergency Room 1
socio-economic characteristics of participants and frequencies Medication 2
Lifetime
and percentages (N, %) were reported. All individuals that No 16 51.6
participated in one or more of the M-Body sessions were Yes 15 48.4
included in the analyses (N 29). All analyses reported utilize Individual Therapy 13
combined data from the two pilot groups. Paired sample t-tests Group Therapy 2
Medication 3
were performed to compare scores from baseline to 8-weeks,
Meditation experience
8e16 weeks and baseline to 16 weeks for all continuous primary Past
outcome measures. Additionally, subscale scores on the mind- No 14 45.2
fulness, well-being and stigma measures were analyzed, using Yes 16 51.6
paired sample t-tests. All summed total scores (with >80% of Current
No 24 77.4
items answered) on all primary outcomes were used in paired Yes 7 22.6
samples t-tests. The effect size (Cohen's d) of paired samples t- Yoga experience
tests were calculated with respective t-values and total sample Past
sizes. The correlation between the change in mindfulness and No 22 71.0
Yes 9 29.0
change in other measures was calculated using Pearson (r) or
Current
Spearman's (rs) correlation coefcient depending on the distri- No 29 93.5
bution of the data. Statistical signicance was set at p < 0.05 and Yes 2 6.5
Condence Intervals (CI) were reported at 95% level. All
 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67 63

statistical analyses were performed in SPSS (Version 22).
3. Results
3.1. Referral, screening, and enrollment
A total of 86 individuals were referred and contacted for po-
tential participation in the M-Body groups, 55 were screened for
depressive symptoms using the QIDS-C or IDS-C (QIDS-C 6e24,
IDS-C 12e59) and 50 were eligible for study participation. Of
the eligible women, 31 completed the baseline assessments and
enrolled in the study. Reasons for losses included schedule con-
ict, no response, disconnected number, medical complications,
not a patient at the FQHC and concern about ability to do yoga.
Fourteen women enrolled in the rst pilot group and attended at
least 1 session, with a mean session attendance rate of 6.4 ses-
sions (8e12 participants per session). One participant dropped
out after attending one session due to a schedule conict.
Seventeen women enrolled in the second pilot group, 15 atten-
ded at least 1 session, with a mean session attendance rate of 6.6
(8e13 participants per session). Two participants dropped out
before attending the rst session; one discontinued due to
stigma associated with depression and depression treatment and
the other was lost due to having an inaccurate phone number.
Another participant attended one session and dropped out due to
a perceived religious conict and another participant attended 3
sessions and dropped out due to personal circumstances.
3.2. Participant characteristics
Participant age ranged from 26 to 67 years with a mean age of
51.9 years. Over half (58%) of the women were single and never
married. Ten women (32%) had a high school diploma or less. Less
than half (45%) of the women were employed part or full time and
10 were either unemployed or disabled. Thirty-ve percent of
women had a yearly personal income of less than $19,999. Seven
women had private insurance, eight had Medicare and nine had
Medicaid (Table 1).
Most women (N 28) reported one or more chronic health
conditions. The most common chronic health conditions were
hypertension (N 12), high cholesterol (N 11), depression
(N 11), and arthritis (N 11). One-third (35%) reported being
previously diagnosed with a depressive disorder. Additionally,
48% reported utilizing mental health services in their lifetime
and 12% in the past year. Of the women who reported utilizing
mental health services, the majority (86%) reported participating
in individual therapy.
Forty-seven percent of the women reported no prior experience
with meditation, 23% had meditated once or occasionally and 30%
reported practicing meditation regularly or semi-regularly. The
majority (71%) reported no past experience with yoga and 20% had
practiced yoga once or occasionally. At the time of the study, 77% of
participants did not practice meditation and 90% did not practice
yoga.
3.3. Home practice
On average, 10 out of 29 participants completed formal
homework (sitting meditation, body scan, yoga) each week.
Participants practiced an average of 4 days a week. Total time
spent practicing ranged from 13 min to 546 (mean 156 min)
minutes per week. Body scan (77 min per week) was practiced
the most, followed by meditation (61 min per week) and yoga
(24 min per week). On average, 11 out of 29 participants
completed weekly informal homework assignments.
3.4. Primary outcome and secondary outcomes
The majority of participants endorsed mild to moderate symp-
toms of depression at baseline (N 22), 8-weeks (N 13) and 16-
weeks (N 12). At 8 and 16 weeks, more participants became
asymptomatic (N 6 at 8 weeks, N 8 at 16 weeks). Participants
demonstrated a signicant decrease in depressive symptoms from
baseline to 16-weeks (p 0.04, t 2.14, Cohen's d 0.84). No
signicant change was found in depressive symptoms from base-
line to 8 weeks and 8e16 weeks (Table 2).
Participants showed a signicant increase in mindfulness from
baseline to 8 weeks (p 0.04, t 2.21, Cohen's d 0.88) and
baseline to 16 weeks (p 0.01, t 2.72, Cohen's d 1.06). Of the
mindfulness subscales, only Observe increased signicantly from
baseline to 8-weeks (p 0.001, t 3.71, Cohen's d 1.48) and
baseline to 16-weeks (p < 0.001, t 4.11, Cohen's d 1.61). The
other subscales (Describe, Act with Awareness, Non-judge and
Non-react) did not change signicantly at either of the post-
intervention assessment points.
Participants also demonstrated a signicant decrease in stress

Table 2
Changes in primary outcomes among participants in the M-Body intervention.

Measures Baseline 8 weeks 16 weeks

n* M SD n M SD n M SD

IDSSR 29 27.21 11.05 25 25.16 15.30 26 23.23 12.72

Depression 29 10.03 6.90 25 8.72 7.51 26 9.85 7.04
Functioning 29 20.14 6.36 25 16.16 6.99 26 17.23 7.07
Stress 29 172.41 28.33 25 183.24 28.91 26 179.04 33.20
Well-being 29 125.79 18.52 25 133.52 19.29 26 136.58 23.28
Mindfulness 28 99.25 33.62 24 119.88 37.15 24 104.38 32.99

Measures Baseline-8wks 8-16wks Baseline-16wks

n Mean Mean t- p- Effect size n Mean Mean t- p- Effect size n Mean Mean t- p- Effect size
T1 T2 score value (d) T2 T3 score value (d) T1 T3 score value (d)

Depression 25 27.40 25.16 1.07 0.30 0.43 24 25.79 23.08 1.40 0.17 0.57 26 27.38 23.23 2.14 0.04 0.84
Functioning 25 9.76 8.72 0.75 0.46 0.18 24 9.08 9.96 0.98 0.34 0.40 26 10.04 9.85 0.15 0.89 0.06
Stress 25 19.76 16.16 2.65 0.01 1.06 24 16.63 16.54 0.09 0.68 0.04 26 20.35 17.23 2.61 0.02 1.02
Well-being 25 173.56 183.24 1.90 0.07 0.76 24 181.96 180.29 0.42 0.93 0.17 26 173.50 179.04 1.19 0.24 0.47
Mindfulness 25 126.48 133.52 2.21 0.04 0.88 24 132.75 136.83 1.85 0.08 0.76 26 126.19 136.58 2.71 0.01 1.06
Stigma 24 102.71 120.54 2.36 0.03 0.96 23 122.35 105.17 2.54 0.02 1.06 25 101.68 102.96 0.19 0.85 0.07
*
Only participants who attended at least 1 M-Body session were included in analyses.
64 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67

from baseline to 8 weeks (p 0.01, t 2.65, Cohen's d 1.06) and

Stigma
baseline to 16 weeks (p 0.02, t 2.61, Cohen's d 1.02) (see

0.01
0.97
Table 3).
No signicant changes were found across the three time-points

Well-being
(baseline to 8-weeks, 8e16-weeks, baseline to 16 weeks) on
overall well-being. However, there was a signicant increase on

0.001
0.69
the Self-Acceptance (p 0.02, t 2.53, Cohen's d 1.01) and
Personal Growth subscales (p 0.04, t 2.2, Cohen's d 0.88)
from baseline to 8-weeks. There were no signicant changes

0.46
Stress

0.002
found across the three time-points (baseline to 8-weeks, 8e16-
weeks, baseline to 16 weeks) on functioning.
Finally, participants demonstrated a signicant increase in

Functioning
depression stigma from baseline to 8-weeks (p 0.03, t 2.36,
Cohen's d 0.96) and decrease from 8 to 16-weeks (p 0.02,

0.24
0.24
t 2.54, Cohen's d 0.02); however the decrease did not return to

Baseline-16wks
baseline. Upon examining the depression stigma subscales, there
was a signicant increase in Treatment Stigma (p 0.04, t 2.17,

Depression
Cohen's d 0.88) from baseline to 8-weeks but a signicant

0.49
decrease in Public Stigma (p 0.04, t 2.24, Cohen's d 0.93),

0.01
Treatment Stigma (p 0.04, t 2.198, Cohen's d 0.92) and
General Self-stigma (p 0.05, t 2.08, Cohen's d 0.87) subscales

Stigma

0.12
from 8 to 16-weeks.

0.6
Upon examining the correlation between change in mindful-
ness and the other outcomes, there was a signicant moderate

Well-being
negative correlation between change in mindfulness and change
in depression (r 0.48, p 0.01) as well as a signicant mod-

0.15
0.3
erate positive correlation between change in mindfulness and

Correlation between change in mindfulness and change in other primary outcomes among participants in the M-Body intervention.
change in well-being (r 0.6, p 0.001) from baseline to 8-weeks.
From 8 to 16-weeks, a signicant moderate negative correlation

0.14
Stress

0.52
between change in mindfulness and change in functioning
(r 0.49, p 0.02) was observed. From baseline to 16-weeks,

Functioning
there was a signicant moderate negative correlation between
change in mindfulness and change in depression (r 0.49,

0.49
p 0.01), and change in mindfulness and change in stress

0.02
(r 0.46, p 0.02), as well as a signicant moderate positive
correlation between change in mindfulness and change in well-
Depression

being (r 0.69, p 0.001).

8-16wks

0.35
0.09

4. Discussion

This study examined the feasibility and preliminary effective-

Stigma

0.39
0.06

ness of a Mindfulness Based Stress Reduction intervention

adapted for depressed disadvantaged women in an urban FQHC
(M-Body). We found that women were interested in participating
Well-being

in the intervention; more than 80 women were referred, and the

0.001

majority of them were self-referred. Further, most of the women

0.6

who were referred and screened were eligible for the study (91%),
which demonstrates the high level of mental health need among
0.31
Stress

adult women in the FQHC. A proportion (50%) of referrals were

0.13

lost due to their unresponsiveness to calls, time constraints and

their perceived inability to do the yoga portion of the group.
Functioning

Future studies should examine the factors that might lead women
to self-identify a mental health need, express interest in partici-
0.19
0.35

pating in an intervention and later disengage.

On average, participants demonstrated pre-post changes in
Baseline-8wks

most of the outcomes in the expected direction of decreases in

Depression

depression and stress and increases in mindfulness and well-

0.48

being. Participants demonstrated a signicant increase in overall

0.01

mindfulness from baseline to 8 weeks and baseline to 16 weeks

and a signicant increase on the observe mindfulness subscale
Mindfulness X

from baseline to 8 weeks and baseline to 16 weeks. These results

Spearman rs

are consistent with prior work conducted by Refs. [70,71] exam-

Pearson r
p-value

p-value

ining the effects of short-form MBSR on psychological outcomes

Table 3

among 23 predominantly African-American female patients at an

inner city FQHC [70,71]. One of the primary aims of M-Body (and
 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67
MBSR) is to help participants develop a conceptual understanding
of mindfulness and integrate formal and informal mindfulness
practices into their daily lives. As a part of the formal practice,
participants are instructed to observe their moment to moment
cognitive, emotional and physiological experiences; therefore it is
not surprising that there was a signicant increase on the observe
subscale of the mindfulness measure. Participants anecdotally
noted their increased ability to make observations about their be-
ing that had previously gone unnoticed.
Participants also demonstrated signicant decrease in stress
from baseline to 8- weeks and baseline to 16 weeks [70,71]. found a
non-signicant decrease in stress [70,71]. This aligns with expec-
tations given that the M-Body didactics specically addresses
identifying stressors, attending to the physiological stress response
system, stress management psychoeducation and coping skills.
Eligibility criteria for participation in M-Body required referrals
to meet a relatively low threshold of depressive symptoms (6 on the
QIDS-C or 12 on the IDS-C). We opted to have a wide range for
eligibility as MBSR, the intervention upon which M-Body is based,
has been shown to improve physical and mental health [5,43,55].
There was notable variability between participants, at each time
point, on depression symptom scores. Average depression scores
decreased from baseline to 8-weeks and 8e16 weeks; however, a
signicant reduction in depressive symptoms was only found from
baseline to 16 weeks. It may be that as participants continued to
practice the formal and informal mindfulness skills after the group
ended, depressive symptoms continued to decline. Participants in
the group were largely from low-income disadvantaged back-
grounds; many of them may have been experiencing signicant
levels of environmental stress that contributed to their depressed
mood. Participants reported unstable housing, difculty caring for
multiple children and strained marital relationships as psychoso-
cial stressors that may have impacted the degree to which
depressive symptoms could be mitigated.
We found that although average well-being scores increased
across the 3 time points, the changes did not reach statistical sig-
nicance. However, we did nd signicant increases on the sub-
scales of acceptance (i.e., In general I feel condent and positive
about myself) and personal growth (i.e., I have a sense that I
have developed a lot as a person over time) from baseline to 8-
weeks. The concept of acceptance is one of the attitudes of
mindfulness that is focused on throughout the M-Body group.
Additionally, much of the group is spent processing how mindful-
ness and stress management skills can be incorporated into the
participants' daily lives. The group noted their increased abilities to
manage their reactions to stressors and reported a sense of growth
and accomplishment and being in control. To our knowledge, no
prior studies have examined the impact of MBSR on well-being in a
disadvantaged population. [32]; examined the impact of a mind-
fulness based intervention on life satisfaction in a low-income
population with multiple chronic physical and psychological con-
ditions and found a pre-post increase in life satisfaction [32].
In contrast with our hypotheses, M-Body participants demon-
strated a signicant increase in depression stigma from baseline to
8 weeks; depression stigma decreased from 8 weeks to 16 weeks,
but did not return to baseline, resulting in an overall increase in
depression stigma scores. Existing literature suggests that African
American individuals report high stigma beliefs associated with
mental health treatment and these stigma beliefs may be a barrier
for seeking help [15,20,50]. M-Body, as an alternative mental health
treatment, may have initially been perceived as more acceptable to
participants, in turn, reducing potential hesitation to participate.
This is evidenced by the large number of participants who self-
referred. Over the course of the intervention, the participants'
increased mindfulness (awareness) may have led them to become
65
more susceptible to real or perceived cues from their surroundings
that trigger and perpetuate depression stigma [56]. The increased
stigma, however, did not appear to contribute to dropout from the
intervention. Attendance rates in the M-Body intervention were
higher than standard psychological interventions.
The results of this study should be taken within the context of
several limitations. The M-Body intervention was conducted as a
pilot study with women only and the sample size is relatively small
(N 31). Therefore, these results may not be generalizable to other
FQHCs with different socio-demographic patient populations or
organizational characteristics. Based on our pilot data, we have
calculated that a sample size of 160 (80 per arm) would be needed
in order to detect an effect size of 0.43 between groups in a future
RCT, accounting for a 20% attrition rate. It is critical that rigorous
RCTs with both genders are conducted in the FQHC setting to
determine the effectiveness of mindfulness based interventions
compared to other evidence based treatments as well as mecha-
nisms of effect. Further, it is key that factors related to successful
implementation, dissemination and sustainability in the FQHC
setting are also explored. We did not consistently collect data on
referral sources. Future studies should collect this data to improve
access and participation in the intervention and understand factors
related to implementation of the program within the clinic. Given
the small sample, and the irregular reporting of home practice, we
were unable to examine the effects that attendance and home
practice may have had on the primary and secondary outcomes.
This should be examined as a covariate in future studies. Similarly,
many of the participants that were enrolled in the study were
experiencing a high levels of environmental and interpersonal
stressors, which may have impacted their ability to optimally
participate in the program, as well as affected their mental health
outcomes over the course of participation. Future studies should
examine the social, demographic and clinical characteristics that
are associated with positive outcomes and ways to improve the
likelihood for success among those who are experiencing more
challenges.
In sum, preliminary data suggest that a mindfulness based
intervention for depression is feasible and positively impacts
multiple psychological outcomes among high-risk disadvantaged
depressed women in a FQHC. Further, mindfulness was positively
correlated with well-being and negatively correlated with depres-
sion from baseline to 8 weeks, suggesting that mindfulness may be
the mechanism of effect on other psychological outcomes. Notable
numbers of women self-identied a need for a mental health
intervention and were willing to enroll and participate which
demonstrates surface acceptability. Strengthening collaborations
with FQHC providers and leadership would likely further improve
the identication of individuals with a need for treatment as well as
the referral network. The M-Body intervention was developed to
use mindfulness as a tool to reduce cognitive and physiological
responses to stress. We found that in fact participants in the
intervention demonstrated a signicant reduction in stress and
increase in mindfulness. More research is needed to determine the
specic mechanisms of effect of mindfulness based interventions
and other psychological outcomes that mindfulness based in-
terventions may positively impact.
Acknowledgments
The authors would like to acknowledge the contributions of the
patients and staff at the Near North Health Centers and Carly
Maletich for mindfulness and intervention development consulta-
tion, and the Agency for Healthcare Research and Quality K12 for
funding that supported this work (AHRQ K12HS023011).
66 I.E. Burnett-Zeigler et al. / Complementary Therapies in Clinical Practice 25 (2016) 59e67

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