| Objective:Based on the literature review and theoretical basis,this study determined the research questions and intervention types,and clarified the reasons and feasibility basis for the selection of mindfulness-based therapy and repetitive transcranial magnetic stimulation.According to the results of systematic evaluation,combined with the physical and mental status and treatment characteristics of patients with post-stroke depression during rehabilitation,the"Internet+"mindfulness-based intervention program was constructed through expert meeting method and pre-test.To evaluate the effect of the intervention program through randomized controlled trials,and to explore the synergistic effect of combined"Internet+"mindfulness therapy on the basis of high-frequency repetitive transcranial magnetic stimulation.Methods:1.Literature review and theoretical basis:Through the literature review,the literature was divided into three parts:post-stroke depression,mindfulness-based therapy,and repetitive transcranial magnetic stimulation.The theoretical basis was based on a cognitive perspective for depression,the relational framework theory,and the mindful meaning construction theory.2.Systematic review of Web-based mindfulness intervention for patients with comorbid somatic depression:Eight Chinese and English databases were systematically searched.According to the inclusion and exclusion criteria,randomized controlled trials on web-based mindfulness intervention for patients with comorbid somatic depression were included.The search time was from the establishment of the database to June 2022.The random effects model was used to analyze the intervention effect by calculating the mean difference(SMD)and 95%confidence interval(CI).The effects of Web-based mindfulness intervention on anxiety,depression,trait mindfulness,quality of life and sleep quality were discussed.The Cochrane Handbook of Systematic Review of Intervention Studies(5.1)randomized controlled trials"Risk of bias assessment"tool for evaluating literature quality,I~2evaluates heterogeneity.3.Constructed an"Internet+"mindfulness-based intervention program:A mindfulness intervention team was established.According to the relevant content and theoretical basis of literature review,the formal practice part of mindfulness-based cognitive therapy was selected as the main practice content,and the key technologies of acceptance and commitment therapy were integrated.Considering the physical conditions of stroke patients,the practice method referred to the mindfulness-based stroke rehabilitation model,combined with the intervention duration,frequency,guidance method and network type included in the systematic evaluation,the first draft of"Internet+"mindfulness intervention program was constructed,and the first draft was revised through expert meeting method and pre-test.Mental health experts and rehabilitation physicians determined the combination with repetitive transcranial magnetic stimulation.4.Effect evaluation of the"Internet+"mindfulness-based therapy combined with repetitive transcranial magnetic stimulation for patients with post-stroke depression:A randomized controlled study design was used to select 72 patients with post-stroke depression who volunteered to participate in this study from January to August 2022 in the rehabilitation medical center of a tertiary hospital in Shanxi and randomly divided into the combined intervention group(n=24),the mindfulness intervention group(n=24)and the waiting control group(n=24).The combined treatment group received"Internet+"mindfulness intervention combined with high-frequency repetitive transcranial magnetic stimulation,the mindfulness intervention group received"Internet+"mindfulness intervention and sham stimulation,and the waiting control group received sham stimulation and general psychological care.The waiting control group was given mindfulness guidance audio and materials immediately after the end of the experiment.The depression status,cognitive function,activities of daily living,and sleep quality of the participants were assessed at baseline(T0),post-intervention(T1),and 8-week post-intervention(T2).Repeated measures analysis of variance was used to compare the intervention effects of the three groups,and Pearson correlation analysis was used to explore the correlation and predictive effect of cognitive function,activities of daily living,sleep quality and depression.Results:1.Results of systematic review and Meta-analysis:A total of 12 randomized controlled trials were included.Web-based mindfulness intervention could improve the levels of anxiety and depression and trait mindfulness for patients with somatic depression comorbidity but had no effect on the improvement of quality of life and sleep quality.According to the type of intervention,the results of subgroup analysis showed that acceptance and commitment therapy did not significantly improve anxiety and depression,but the two studies were highly heterogeneous,and descriptive analysis was needed.Participants’depressive status remained somewhat valid at 3 months after the Web-based mindfulness-based intervention.2.Protocol construction results(1)The first draft of the"Internet+"mindfulness-based intervention program:a total of 6 researchers participated in the construction,and the intervention platform selection We Chat and Tencent conferences.The content of the intervention included 7 themes:New understanding of mindfulness and challenging old thinking;Automatic navigation and self-acceptance;Coping disorder,cognitive dissociation;Breathing mindfulness and being present;Living in the present moment;Thoughts are not facts,clarifying values;Allow it to happen as scheduled,commit to action.The audio and information were sent to the We Chat group,and those who participated in the course less than once were asked the reason immediately and given help.The intervention lasted for 6 weeks,with 40-60minutes for each course and 20-45 minutes for homework practice every day.(2)Results of expert meeting:A total of 7 experts participated in the revision of the program,including 3 mindfulness-based therapy experts,1 rehabilitation nursing specialist nurse,1 rehabilitation doctor,and 2 clinical psychologists.The program was revised as follows:The metaphor of"man in the pit"was revised as an example that was appropriate to the patient’s treatment;changing the"lie detector metaphor"into the practice of holding a glass of water in daily life;The"making a commitment to connecting with values"in week 6 was combined with"clarifying values"in week 5,and the content was changed to write a short letter to yourself from 5 years later.If you are unable to write,you can complete it with the assistance of your family or imagination.Add a small part in the sixth lesson to discuss what outside help and resource sharing can be sought in the process of achieving our goals.(3)Results of pilot study:Five patients with post-stroke depression who were in a stable condition and had a bachelor’s degree or above in the rehabilitation period and their family members were recruited to complete the 2-week intervention.The contents were modified as follows:word documents were removed;the content was sent in the dialog box in a short and clear way,with an audio and short video as the main content;public tweets were reduced;adding rehabilitation exercises appropriately and applying mindfulness skills;The intervention time was 7:30-8:30 p.m.every Saturday.(4)Results of mindfulness-based therapy combined with High-frequency repetitive transcranial magnetic stimulation:Two mental health experts with relevant research experience of repetitive transcranial magnetic stimulation for patients with depression and one rehabilitation physician participated in the development of the program.Stimulation site:the left dorsolateral prefrontal cortex;Stimulation intensity:80%motor threshold;Stimulation duration:5 days a week for 4 weeks;Combined method:completing a3-minute breathing space exercise before each session,breathing meditation guidance audio was played during the session.In addition,they received"Internet+"mindfulness therapy for 6 weeks as normal.3.Results of randomized controlled trials(1)A total of 80 patients were recruited in this study.1 case was excluded because of severe cognitive impairment,2 cases were excluded because of not meeting the inclusion criteria,and 5 cases were unwilling to participate in this study.There were 23 cases in the combined treatment group,24 cases in the mindfulness-based intervention group,and 24cases in the waiting control group.There were 58 males(81.7%)and the average age of the patients was 55.41±13.75.There was no significant difference in general data among the three groups.(2)Intervention compliance:8 patients completed the course 1～3 times,15 patients completed the course 4～6 times(65.2%)in the combined treatment group,and 9 patients completed the course 2～3 times,14 patients(58.3%)completed the course 4～6 times in the mindfulness intervention group.A chi-square test was performed on the participation rate of the two groups,and the results were not statistically significant(X~2=0.236,P=0.766).(3)Depression score:There was no significant difference in the depression scores of the three groups before intervention(F=2.032,P=0.139).After the intervention,the depression scores of the three groups were significantly different from those before the intervention(P<0.05).The combined intervention group decreased from(19.04±2.16)to(13.96±2.99)and(11.96±3.24)points,the mindfulness intervention group decreased from(19.13±3.05)to(15.63±2.02)and(13.96±2.14)points,and the waiting control group increased from(20.25±1.39)to(17.38±1.41)points and then increased to(17.54±2.25)points.The trend of depression in the combined treatment group was more significant than that in the other two groups.Repeated measures analysis of variance showed that the inter-group effect was statistically significant(F=17.997,P=0.001),that was a statistically significant difference in depression scores between different interventions.The scores of the three groups at different time points were statistically different(F=183.610,P<0.001).The interaction between group and time was statistically significant(F=11.157,P<0.001).(4)Cognitive function score:There was no significant difference in the cognitive function scores of the three groups before intervention(F=0.250,P=0.779),but there was a significant difference after intervention(P<0.05).The cognitive function scores of the combined intervention group increased from(21.09±4.33)to(26.48±1.27)and(27.00±1.28)points.The score of the mindfulness intervention group increased from(20.83±5.59)to(25.46±2.90)points decreased slightly to(25.04±1.63),while the scores of the waiting control group increased from(20.04±5.83)to(22.50±3.86)and then decreased to(21.54±3.43)points.Repeated measures analysis of variance showed that the scores of different intervention groups were statistically significant(F=7.594,P=0.001),the main effect of time at different time points was statistically different(F=63.639,P<0.001),and the interaction effect of time and group was statistically significant(F=5.114,P=0.001).(5)Sleep quality score:There was no significant difference in the sleep quality scores of the three groups before the intervention(F=1.952,P=0.150),but there were significant differences after the intervention compared with before intervention(P<0.05).The sleep quality scores of the combined intervention group decreased from(10.87±1.87)to(7.43±1.70)and(4.35±1.19)points.The scores of the mindfulness intervention group decreased from(11.79±2.54)to(9.08±2.62)and(6.88±2.85),while the scores of the waiting control group decreased from(10.54±2.34)to(8.67±2.20)and then increased to(8.75±2.94).Repeated measures analysis of variance showed that the scores of different intervention groups were statistically significant(F=5.603,P=0.006),the main effect of time at different time points was statistically different(F=192.487,P<0.001),and the interaction effect of time and group,was statistically significant(F=19.629,P<0.001).(6)Scores of activities of daily living:There was no significant difference in the scores of activities of daily living among the three groups before intervention(F=0.157,P=0.855),but there were significant differences after the intervention compared with before intervention(P<0.05).The scores of activities of daily living in the combined intervention group gradually increased from(46.52±19.45)to(75.43±9.40)and(81.96±9.50).The scores of activities of daily living in the mindfulness intervention group increased from(45.00±18.00)to(66.46±9.03)and(75.00±7.37),while the scores in the waiting control group increased from(43.75±12.87)to(65.83±8.43)and(71.46±6.83).Repeated measures analysis of variance showed that the scores of different intervention groups were statistically significant(F=3.297,P=0.043),the main effect of time at different time points was statistically different(F=400.377,<0.001),and the changing trend of participants in the three groups over time,namely the interaction effect of time and group,was statistically significant(F=2.903,P=0.024).(7)Potential predictors of improvement in depressive symptoms after intervention:Pearson correlation analysis showed that depressive symptoms were negatively correlated with cognitive function and activities of daily living(r=-0.455,<0.001;r=-0.580,<0.001),and positively correlated with sleep quality(r=0.410,<0.001).The correlation analysis between the baseline scores of the subjects’outcome indicators and T2 time points showed that the degree of depression at the 8-week follow-up was negatively correlated with the baseline level of cognitive function(r=-0.263,=0.027).Conclusion:Through literature review,it was found that depression affected the prognosis of stroke patients in rehabilitation period,resulting in decreased cognitive function,activities of daily living and sleep quality.In this study,they were evaluated as important outcome indicators.A cognitive perspective for depression supports the interaction between depression and cognitive function,so whether the cognitive function can be used as a predictor of the degree of improvement in depression was explored.The results of the relational framework theory,mindfulness meaning construction theory,and systematic review supported the effectiveness of Web-based mindfulness intervention for patients with somatic depression comorbid.Combined with Mindfulness-Based Recovery from Stroke,the"Internet+"mindfulness therapy for patients with post-stroke depression was constructed.In actual clinical practice,it has been found that patients with post-stroke depression usually receive repetitive transcranial magnetic stimulation,but due to the high cost of treatment,the presence of contraindications and adverse reactions,some patients are unable to receive this physical therapy.Randomized controlled trials have found that repetitive transcranial magnetic stimulation combined with"Internet+"mindfulness therapy and"Internet+"mindfulness therapy alone can improve the emotional state and clinical outcomes of patients,the combined treatment showed a synergistic effect,which verified that"Internet+"mindfulness intervention can be promoted as a potential nursing aid.The baseline level of cognitive function can be used as a potential predictor of recovery from depression after the intervention,so as to evaluate the effectiveness of recovery.In the future,it is necessary to further simplify the mindfulness intervention program,develop an APP that is easy to promote,expand the sample size,extend the follow-up time,and evaluate the psychological mechanism of combined intervention. |
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