Meditation-based Interventions Might be Helpful for Coping with the Corona Virus Disease 2019 (COVID-19)

JIANG Yan-yu (蒋艳玉), YANG Xi (杨 晞), TONG Hui-qi (童慧琦), FANG Bang-jiang (方邦江), LI Bin (李 斌),GONG Ya-bin (龚亚斌), MA Xin (马 昕), ZHENG Jun-hua (郑军华), ZHOU Feng (周 锋),YANG Zhi-tao (杨之涛)0, CHEN Xiao-yun (陈晓云), DONG Chang-sheng (董昌盛),ZHANG Yan-mei (张艳梅)#, XU Jian-guang (徐建光)#, JIA Li-jun (贾立军)

1. Cancer Institute, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China;2. Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, California 94305, USA;3. Mindfulness Program, Stanford Center for Integrative Medicine, California 94305, USA; 4. Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China; 5. Department of Dermatology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China, 6.Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China. 7. Huashan Hospital, Fudan University, Shanghai 200040, China.8. Department of Urology, Shanghai General Hospital, School of Medicine in Shanghai Jiao Tong University, Shanghai 200080, China. 9. Department of Respiratory Disease, Qingpu Branch of Zhongshan Hospital af filiated to Fudan University,Shanghai 201700, China. 10. Emergency Department, Ruijin Hospital af filiated to Shanghai Jiaotong University, School of Medicine, Shanghai 200025, China. 11. Department of Rheumatology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China. 12. Department of Laboratory Medicine, Huadong Hospital, Fudan University,Shanghai 200040, China; 13. Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai 200040, China; 14. School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China is co- first authors.

ABSTRACT The Coronavirus Disease 2019 (COVID-19) has been characterized as the first pandemic caused by a novel coronavirus and drawn intense attention in China and globally. With the incidence and mortality rates of COVID-19 rapidly growing worldwide, people have been experiencing tremendous psychological distress during the pandemic. Elevated psychological stress could compromise the human capacity to fight against COVID-19.However, effective interventions and timely mental health care to increase resilience and improve psychological wellbeing is still lacking, which would be the focus of this article. In this article, we brie fly summarize why meditation practice may have the potential to help minimize stress-related psychological symptoms associated with the coronavirus outbreak and how we can respond efficiently and effectively to this outbreak via taking advantage of meditation. We also provide a brief introduction of a meditation program that we developed and advocate to popularize meditation practice as a viable approach to improve wellbeing while combatting COVID-19 worldwide.

KEYWORDS COVID-19; Psychological stress; Meditation; Bodily sensation; Emotional trauma

COVID-19 OUTBREAKS GLOBALLY

The Coronavirus Disease 2019 (COVID-19),first reported in Wuhan, Hubei, China, has been characterized as the first pandemic caused by a coronavirus and drawn intense attention in China and globally[1]. Due to human-to-human transmission,the incidence and mortality rates of COVID-19 are rapidly growing worldwide[1]. Up to March 20th, 2020,at least 81,300 diagnosed cases and 3,253 deaths have been reported in China. Apart from China,152,773 confirmed cases and 6,587 deaths with COVID-19 have been diagnosed from 175 countries and territories, and Europe has now turned into the epicenter of this pandemic, including Italy (41,035 diagnosed cases), Spain (17,147 diagnosed cases),Germany (10,999 diagnosed cases), and France(10,877 diagnosed cases) (https://experience.arcgis.com/experience/685d0ace521648f8a5beee ee1b9125cd). With the rapid spread of COVID-19 globally, authorities and the public have been deeply concerned both by the alarming levels of spread and severity, and by its tremendous negative impacts on public health, economy and stability of society.

PEOPLE IN HUGE PSYCHOLOGICAL DISTRESS IN FIGHTING AGAINST COVID-19

Public health measures, such as isolation,quarantine, travel restriction, and the lock-down of heavily affected cities such as Wuhan since January 23rd, 2020, are deemed necessary for COVID-19 containment and mitigation[2]. However,negative psychological effects such as fear, anxiety,boredom, depression, even suicide are likely to arise[3,4]. Indeed, people have been experiencing tremendous psychological stress while fighting against COVID-19. Firstly, patients confirmed with COVID-19 infection are unprepared for the emotional trauma associated with the diagnosis, treatment and prognosis, resulting in fear, anxiety, depression and insomnia[4]. Meanwhile, bodily sensations such as fever, coughing, vomiting and dyspnea can exacerbate psychological stress. Secondly,people under investigation may experience fear and anxiety during the period of waiting for test results. In addition, separation from families and a sense of con finement would contribute to worsening psychological distress[2]. Thirdly, healthcare providers are confronted with enormous pressure, such as overwork, exhaustion, isolation, high risk for infection,which could lead to mental conditions such as anxiety,depression, sleeplessness and frustration[5]. Fourthly,with elevated numbers of new cases and deaths,escalated media reporting, confinement, uncertainty over the course of disease and inadequate supplies(such as masks, food, water and daily supplies),anxiety at a community level is increasing[2,4,6].

ELEVATED PSYCHOLOGICAL STRESS HAS NEGATIVE IMPLICATIONS ON THE FIGHT AGAINST COVID-19

Elevated psychological stress would have a number of negative implications. Firstly, it would disrupt the therapeutic effect of the patients, the attention of healthcare providers as well as the decision-making process of policy-makers. Secondly,psychological stress may have a lasting effect on the overall psychological wellbeing[7]. Xiang YT et al. reported that post-traumatic stress disorders,depression and chronic fatigue still existed widely among severe acute respiratory syndrome (SARS)survivors even a decade after the outbreak of SARS in 2003[7]. Furthermore, accumulated evidence also showed that psychological stress could impair antiviral immune responses and increase the release of inflammatory factors[8], which are crucial for the development and progression of COVID-19[1].Therefore, effective interventions and timely psychological health care needs to be developed urgently.

MEDITATION-BASED INTERVENTIONS TO COPE WITH COVID-19

In the past 40 years or so, meditation,rooted in ancient oriental culture and gained momentum in western psychology research and practice, has been proven effective in reducing psychological stress, enhancing disease treatment and recovery, and improving the quality of life in various populations[9,10]. Meditation is a mental practice which aims to promote psychological ability (such as cognitive function and emotional regulation)[9,10]. We speculate that mediation may serve as an effective intervention for those who are fighting against COVID-19 pneumonia via the following mechanisms. Firstly, meditation enables individuals to pay attention to the present moment via directing and focusing the mind on a particular/certain object such as breathing or physical sensation. This gives them a new vantage point to recognize unwholesome emotions and direct their attention more effectively toward self-regulation of the body and mind, thus helping to diminish negative emotions and strengthen the internal motivations to defeat COVID-19. Secondly, meditation may help people recognize and accept COVID-19-related emotions (such as fear, anxiety and depression)and physical symptoms (such as fever, hypoxia,cough and fatigue) as the way things are in this moment, no matter how challenging or terrifying they might be. This different perspective can help promote better emotion regulation through greater acceptance of things as they are, thus enhancing one's capability to fight against COVID-19.Thirdly, stress hormones, such as cortisol, act as immunosuppressive agents, and therefore may hinder the anti-COVID-19 immune response. On the contrary, meditation reduces blood cortisol levels[11],thus enhances anti-viral immune response, resulting in health benefits. Furthermore, meditation reduces inflammation factors[8,12], such as C-reactive protein,which can be significantly elevated and serve as a potential risk factor for negative clinical outcome[1,13].In addition, meditation training is widely accessible,easy to learn and inexpensive, thus meditation serves as an attractive and cost-effective adjunct approach compared to the traditional medical therapy. These facts summarized here clearly indicate that meditation practice has the potential, when well-articulated and effectively delivered to those infected as well as those at risk and care-givers, to help minimize stress-related psychological symptoms such as fear,anxiety and depression and potentially modulate/alleviate the course of the physical disorders in the context of COVID-19. This suggests an important and potentially major role for meditation-based approach in the prevention and treatment of COVID-19-related symptoms, both physical and mental.

SUGGESTIONS ON THE USE OF MEDITATION-BASED INTERVENTIONS FOR COPING WITH COVID-19-RELATED PSYCHOLOGICAL STRESS

How can we respond more efficiently and effectively to this outbreak via taking advantage of meditation? Some suggestions listed here might be helpful to cope with the COVID-19-related psychological stress (Figure 1). Firstly, a multidisciplinary team should be established which includes psychologists, healthcare workers and meditation mentors, who are responsible for designing the meditation training programs for COVID-19,providing psychological counselling, and serving as coaches to help participants complete the practice with good adherence. Secondly, the meditation training program for COVID-19 should integrate body and mind techniques to gain broad positive effects in modulating or alleviating psychological stress, such as relaxation, mental imagery, breathing training and mindfulness practice. Thirdly, the meditation practice would be accompanied by music, which could drive the attention of the mind via continuous sensory input, help relaxing the body quickly and maintaining a good mindful state. In addition, the meditation training program can be disseminated by easy-tocarry electronic devices and applications (such as portable speakers and WeChat, a popular Chinese social media). For easily accessible and non-physical contact training mode, free online meditation lessons can be delivered quite ef ficiently to con firmed cases,people under investigation, healthcare workers and the general public.

CONCLUSION AND PROSPECT

Currently, a meditation training program for COVID-19 was developed by a multidisciplinary team and popularized on WeChat with free access.Meanwhile, the effects and underlying mechanisms of meditation for the treatment of COVID-19-related psychological distress are under investigation by a collaborative research team in Wuhan. We expect meditation-based interventions will have positive impact on reducing the COVID-19 burden and preventing post-traumatic stress disorder in China.With Coronavirus spreading globally, we sincerely hope to communicate with colleagues who are working on COVID-19, and share our work, our experiences and lessons learned.

ACKNOWLEDGMENTS

We thank Dr. Jon Kabat-Zinn, founder of Mindfulness-based Stress Reduction and Professor of Medicine, Emeritus, University of Massachusetts,School of Medicine for his valuable comments on the content of this manuscript. We thank Dr. LIU Hao(Shanghai Conservatory of Music), Dr. JIANG Lei (East China Normal University) , Dr. HUANG Hai-qing and Dr.GE Bing (Shanghai Datatom Information Technology Inc.) for providing technical supports. This study was supported by the Emergency Scientific Research program of Preventing or Treating COVID-19 of Shanghai University of Traditional Chinese Medicine(2019YJ1201), the Scientific Research Program on Prevention and Treatment of COVID-19 with Traditional Chinese Medicine of Shanghai Administration of Traditional Chinese Medicine (2020XGKY15), and Art Project of National Social Science Foundation(No. 16BD050).