Efficacy of Internet-Delivered Mindfulness for Improving Depression in Caregivers of People With Spinal Cord Injuries and Chronic Neuropathic Pain: A Randomized Controlled Feasibility Trial

Published:September 27, 2018DOI:



      To explore the feasibility and efficacy of web-based mindfulness training for carers of people with spinal cord injury (SCI).


      Randomized controlled feasibility study with 3-month follow-up.


      Community setting.


      Spouses or family caregivers (N=55) of people with SCI and chronic neuropathic pain were recruited via the direct care team and advertisements. Participants were older than 18 years (no upper age limit), with Internet access for the duration of the study. Participants were randomly allocated to an 8-week online mindfulness training intervention (n=28), or to receive 8 weeks of psychoeducational materials on SCI and chronic pain (n=27).


      An established web-based, mindfulness training course was delivered over 8 weeks. Participants completed 10 minutes of mindfulness practices, twice per day, 6 days per week, totaling 960 minutes. The control group received a weekly e-mail with psychoeducational materials (based on the established elements) on SCI and pain for 8 weeks.

      Main Outcome Measure

      Depression severity.


      Mindfulness reduced depression severity more than psychoeducation at T2 (mean difference= −.891; 95% confidence interval,−1.48 to −.30) and T3 (mean difference=−1.96; 95% confidence interval, −2.94 to −.97). Mindfulness training also reduced anxiety at T2 (mean difference=−.888; 95% confidence interval, −1.40 to −.38) and T3 (mean difference=−2.44; 95% confidence interval, −3.20 to −1.69).


      Results indicate that Internet-delivered mindfulness training offers unique benefits and is viable for caregivers of people with SCI and chronic neuropathic pain. Further work should explore the feasibility of combined education and mindfulness training incorporating both patient and caregiver, for optimum benefit.


      List of abbreviations:

      FFMQ (Five Facet Mindfulness Questionnaire), HADS (Hospital Anxiety and Depression Scale), MBI (mindfulness-based intervention), QOL (quality of life), SCI (spinal cord injury)
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        • Lynch J.
        • Calahan R.
        The impact of spinal cord injury on the quality of life of primary family caregivers: a literature review.
        Spinal Cord. 2017; 55: 964-978
        • Modirian E.
        • Pirouzi P.
        • Soroush M.
        • Karbalaei-Esmaeili S.
        • Shojaei H.
        • Zamani H.
        Chronic pain after spinal cord injury: results of a long-term study.
        Pain Med. 2010; 11: 1037-1043
        • Widerstrom-Noga E.G.
        • Felipe-Cuervo E.
        • Broton J.G.
        • et al.
        Perceived difficulty in dealing with consequences of spinal cord injury.
        Arch Phys Med Rehabil. 1999; 80: 580-586
        • Murray R.F.
        • Asghari A.
        • Egorov D.D.
        • et al.
        Impact of spinal cord injury on self-perceived pre- and post-morbid cognitive, emotional and physical functioning.
        Spinal Cord. 2007; 45: 429-436
        • Westgren N.
        • Levi R.
        Quality of life and traumatic spinal cord injury.
        Arch Phys Med Rehabil. 1998; 79: 1433-1439
        • Ebrahimzadeh M.H.
        • Shojaei B.S.
        • Golhasani-Keshtan F.
        • Soltani-Moghaddas S.H.
        • Fattahi A.S.
        • Mazloumi S.M.
        Quality of life and the related factors in spouses of veterans with chronic spinal cord injury.
        Health Qual Life Outcomes. 2013; 11: 48
        • Lucke K.
        • Martinez H.
        • Mendez T.
        • Arevalo-Flechas L.
        Resolving to go forward: the experience of Latino/Hispanic family caregivers.
        Qual Health Res. 2012; 23: 218-230
        • Dickson A.
        • O’Brien G.
        • Ward R.
        • Allan D.
        • O’Carroll R.
        The impact of assuming the primary caregiver role following traumatic spinal cord injury: an interpretative phenomenological analysis of the spouse’s experience.
        Psychol Health. 2010; 25: 1101-1120
        • Weitzenkamp D.A.
        • Gerhart K.A.
        • Charlifue S.W.
        • Whiteneck G.G.
        • Savic G.
        Spouses of spinal cord injury survivors: the added impact of caregiving.
        Arch Phys Med Rehabil. 1997; 78: 822-827
        • Lucke K.T.
        • Coccia H.
        • Goode J.S.
        • Lucke J.F.
        Quality of life in spinal cord injured individuals and their caregivers during the initial 6 months following rehabilitation.
        Qual Life Res. 2004; 13: 97-110
        • Hearn J.H.
        • Cotter I.
        • Fine P.
        • Finlay K.A.
        Living with chronic neuropathic pain after spinal cord injury: an interpretative phenomenological analysis of community experience.
        Disabil Rehabil. 2015; 37: 2203-2211
        • Charlifue S.B.
        • Botticello A.
        • Kolakowsky-Hayner S.A.
        • Richards J.S.
        • Tulsky D.S.
        Family caregivers of individuals with spinal cord injury: exploring the stresses and benefits.
        Spinal Cord. 2016; 54: 732-736
        • Schulz R.
        • Czaja S.J.
        • Lustig A.
        • Zdaniuk B.
        • Martire L.M.
        • Perdomo D.
        Improving the quality of life of caregivers of persons with spinal cord injury: a randomized controlled trial.
        Rehabil Psychol. 2009; 54: 1-15
        • Molazem Z.
        • Falahati T.
        • Jahanbin I.
        • Jafari P.
        • Ghadakpour S.
        The effect of psycho-educational interventions on the quality of life of the family caregivers of the patients with spinal cord injury: a randomized controlled trial.
        Int J Community Based Nurs Midwifery. 2014; 2: 31-39
        • Kabat-Zinn J.
        Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness.
        Dell, New York1990
        • Hearn J.H.
        • Finlay K.A.
        Internet-delivered mindfulness for people with depression and chronic pain following spinal cord injury: a randomised, controlled feasibility trial.
        Spinal Cord. 2018; 56: 750-761
        • Krusche A.
        • Cyhlarova E.
        • King S.
        • Williams J.M.
        Mindfulness online: a preliminary evaluation of the feasibility of a web-based mindfulness course and the impact on stress.
        BMJ Open. 2012; 2e000803
        • Carmody J.
        • Baer R.A.
        • LB Lykins E.
        • Olendzki N.
        An empirical study of the mechanisms of mindfulness in a mindfulness-based stress reduction program.
        J Clin Psychol. 2009; 65: 613-626
        • Main N.A.
        • Elliot S.A.
        • Brown J.S.
        Comparison of three different approaches used in large-scale stress workshops for the general public.
        Behav Cogn Psychother. 2005; 33: 299-309
        • Cusens B.
        • Duggan G.B.
        • Thorne K.
        • Burch V.
        Evaluation of the Breathworks Mindfulness-Based Pain Management Programme: effects on well-being and multiple measures of mindfulness.
        Clin Psychol Psychother. 2010; 17: 63-78
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Bjelland I.
        • Dahl A.A.
        • Haug T.T.
        • Neckelmann D.
        The validity of the Hospital Anxiety and Depression Scale: an updated literature review.
        J Psychosom Res. 2002; 52: 69-77
        • World Health Organization
        Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group.
        Psychol Med. 1998; 28: 551-558
        • Skevington S.
        • Lofty M.
        • O’Connell K.A.
        The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A Report from the WHOQOL Group.
        Qual Life Res. 2004; 13: 299-310
        • Baer R.
        • Smith G.T.
        • Hopkins J.
        • Krietemeyer J.
        • Toney L.
        Using self-report assessment methods to explore facets of mindfulness.
        Assessment. 2006; 13: 27-45
        • Mehta S.
        • Orenczuk S.
        • Hansen K.T.
        • et al.
        An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post spinal cord injury.
        Rehabil Psychol. 2011; 56: 15-25
        • Skinner T.C.
        • Roberton T.
        • Allison G.T.
        • Dunlop S.
        • Bucks R.S.
        Experiential avoidance, mindfulness and depression in spinal cord injuries: a preliminary study.
        Aust J Rehabil Couns. 2010; 16: 27-35
        • Williams J.M.
        • Kuyken W.
        Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse.
        Br J Psychiatry. 2012; 200: 359-360
        • Hofmann S.G.
        • Sawyer A.T.
        • Witt A.A.
        • Oh D.
        The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review.
        J Consult Clin Psychol. 2010; 78: 169-183
        • Lehrer P.M.
        • Woolfolk R.L.
        Specific effects of stress management techniques.
        in: Lehrer P.M. Woolfolk R.L. Principles and practice of stress management. Guilford, New York1993: 481-520
        • Roemer L.
        • Orsillo S.M.
        Expanding our conceptualization of and treatment for generalized anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models.
        Clin Psychol Sci Pract. 2002; 9: 54-68
        • Baker K.L.
        • Robertson N.
        Coping with caring for someone with dementia: reviewing the literature about men.
        Aging Ment Health. 2008; 12: 413-422
        • Chen K.W.
        • Comerford A.
        • Shinnick P.
        • Ziedonis D.M.
        Introducing qigong meditation into residential addiction treatment: a pilot study where gender makes a difference.
        J Altern Complement Med. 2010; 16: 875-882
        • Rojiani R.
        • Santoyo J.F.
        • Rahrig H.
        • Roth H.D.
        • Britton W.B.
        (2017). Women benefit more than men in response to college-based meditation training.
        Front Psychol. 2017; 8: 1-11
        • LaVela S.L.
        • Landers K.
        • Eingen B.
        • Karalius V.P.
        • Miskevics S.
        Factors related to caregiving for individuals with spinal cord injury compared to caregiving for individuals with other neurologic conditions.
        J Spinal Cord Med. 2015; 38: 505-514
        • Arango-Lasprilla J.C.
        • Plaza S.L.
        • Drew A.
        • et al.
        Family needs and psychosocial functioning of caregivers of individuals with spinal cord injury from Colombia, South America.
        NeuroRehabilitation. 2010; 27: 83-93
        • Ebrahimzadeh M.H.
        • Shojaee B.S.
        • Golhasani-Keshtan F.
        • Moharari F.
        • Kachooei A.R.
        • Fattahi A.S.
        Depression, anxiety and quality of life in caregiver spouses of veterans with chronic spinal cord injury.
        Iran J Psychiatry. 2014; 9: 133-136
        • Melville K.M.
        • Casey L.M.
        • Kavanagh D.J.
        Dropout from Internet-based treatment for psychological disorders.
        Br J Clin Psychol. 2010; 49: 455-471