The Utility of Meditation and Mindfulness-Based Interventions in the Time of COVID-19: A Theoretical Proposition and Systematic Review of the Relevant Prison, Quarantine and Lockdown Literature

Abstract

As of July 20, 2021, Covid-19 has killed 4,086,000 people, infected at least 190,169,833 others, and devastated the world’s economy. To slow the spread of the virus, numerous governments instituted “lockdown” policies and quarantines, limiting social interactions to the immediate household. The experience of isolation and uncertainty have contributed to increased fear, anxiety, and loneliness; with limited options of research-supported interventions. Although different in nature, the experiences of quarantine and lockdown have been likened to incarceration. Past research has found meditation and mindfulness-based interventions (MBIs) to be effective psychological treatments for prisoners and may therefore translate well into effective methods for the maintenance of psychological well-being for individuals quarantined during the pandemic. More recently, research investigating the effects of meditation and MBIs during the pandemic have demonstrated preliminary evidence for beneficial psychological improvements. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), the current narrative review paper: 1) examines the parallels and differences between the experience of quarantine and imprisonment, 2) investigates the mechanisms through which meditation and mindfulness enact their effects, and 3) systematically reviews literature on the benefits of various types of meditation and MBIs for inmates and individuals in lockdown or quarantine. With this knowledge, the public can garner applicable insight into the potential use of meditation and MBIs for individuals forced to cope with pandemic lockdowns and quarantines. Two hundred and twenty one (221) articles were identified through Pubmed and Google Scholar, and 24 articles were ultimately included in the manuscript.

In December of 2019, the flu-like novel CoronaVirus Covid-19 disease emerged and rapidly spread to nearly every country on the globe (Zhou et al., 2020). On March 11, 2020, Covid-19 was officially declared a pandemic by the World Health Organization (World Health Organization, 2020). As of July 20, 2021, Covid-19 has killed 4,086,000 people, infected at least 190,169,833 others, and devastated the world’s economy (Fernandes, 2020; Loayza & Pennings, 2020; World Health Organization, 2021). Across the world, governments have instituted lockdowns, quarantined entire cities, shut down all non-essential businesses and operations, and instructed hundreds of millions of citizens to practice social distancing and self-quarantine at home (CDC, 2020; Wright, 2020). These orders have contributed to the manifestation of increased levels of fear, anxiety, uncertainty, boredom, depression, and loneliness amongst much of the world’s populace (Sood, 2020). As such, there is a need for interventions to mitigate some of the negative mental health outcomes associated with the trauma of Covid-19 and social isolation.

Given that the world has not grappled with a large-scale pandemic since the early 20th century, there is limited guidance on how to maintain mental health under the current circumstances. Therefore, researchers and clinicians must look to other sources in order to identify parallels which can help guide practice. In some respects, quarantine is similar to the experience of 2.3 million individuals who are currently incarcerated in the United States (Sawyer & Wagner, 2020). The similarities between these experiences include a restriction of personal freedom and confinement to a particular place. Incarceration is also associated with similar psychopathological symptoms such as anxiety, depression, fear, loneliness, insomnia, and maladaptive behavioral responses, as well as the exacerbation of pre-existing mental health difficulties (Brooks et al., 2020; Fazel & Seewald, 2012).

The prison population has long grappled with the consequences of isolation and a body of research has found meditation and mindfulness-based interventions (MBIs) to be effective psychological treatments (Ferszt et al., 2015; Himelstein, 2011; Ifeagwazi et al., 2019; Nidich et al., 2016; Riley et al., 2019; Sumter et al., 2009). Meditation and mindfulness are associated with a reduction of stress, anxiety, depression, and trauma symptoms, as well as improvements in sleep and overall psychological well-being (Ferszt et al., 2015; Nidich et al., 2016). Meditation consists of a diverse array of techniques intended to promote relaxation, enhance emotional and attentional regulatory abilities, and promote a heightened sense of well-being (Davidson & Lutz, 2008), while mindfulness consists of the conscious maintenance of an open and non-judgmental awareness of the present moment (Kabat-Zinn, 2003).

While numerous studies have empirically investigated the utility of meditation and mindfulness in prison (Abrams & Siegel, 1978; Bouw et al., 2019; Bowen et al., 2006; Chandiramani et al., 1995; Ferszt et al., 2015; Ifeagwazi et al., 2019; Nidich et al., 2016; Perelman et al., 2012; Riley et al., 2019; Samuelson et al., 2007; Simpson et al., 2007; Sumter et al., 2009), thus far there have been 11 empirical studies investigating different forms of meditation and MBIs during quarantine (Conversano et al., 2020; Dubey et al., 2020; Haliwa et al., 2020; Jiménez et al., 2020; Matiz et al., 2020; Pizzoli et al., 2020; Saricali et al., 2020; Schnepper et al., 2020; Sweeny et al., 2020; Wielgus et al., 2020; Zheng et al., 2020). This, however, is the only paper of which the authors are aware that draws parallels between prison, quarantine and lockdown, using an integrated multidisciplinary biopsychosocial framework. This framework examines different perspectives (e.g., neuroscience, neuropsychology, clinical psychology, history, and sociology) and multiple levels of explanation (e.g., psychological, physiological, and neurological) to: 1) systematically examine the parallels between the experience of quarantine and imprisonment; 2) analyze the mechanisms through which meditation and mindfulness demonstrates their effects; and 3) review the relevant literature pertaining to the effects of meditation and MBIs in prison, lockdown, and quarantine.

The Pandemic and Associated Adverse Effects

Pandemics and related disasters contribute to maladaptive psychological responses such as mass hysteria, panic, anxiety, post-traumatic stress disorder (PTSD), depression, substance abuse, and hoarding (Goldmann & Galea, 2014; Mawson, 2005; Shultz et al., 2016; Towers et al., 2015). In addition, the stress-related physiological effects attributable to pandemics are known to degrade the body’s natural immunity and increase its inflammatory response, leading to more dire pathophysiology and delayed recovery (Holt-Lunstad et al., 2015; Leonard, 2005; Salim et al., 2012). Financial loss, uncertainty about the future, fear of infection, boredom, and the grievance of loved ones lost (Sood, 2020) are common during a pandemic. The psychological impact of the current pandemic stretches across the age spectrum, with both children and older adults alike experiencing anxiety, stress, and fear (Kontoangelos et al., 2020).

Quarantine-Related Social Isolation and Loneliness

During the Covid-19 pandemic most citizens either voluntarily entered self-isolation to avoid putting themselves at risk of illness or involuntarily entered isolation per orders from the government, hereby referred to as quarantine. Many governments also declared “lockdown” measures, which refer to the implementation of a restriction policy on the movements of people as a precautionary security measure. The severity and adherence to these policies observed during the pandemic have differed by country and government; however, the elements of restriction, involuntariness, and enforcement, still remain as similar elements in both quarantine and lockdown (Shah et al., 2020). Historically, the first documented quarantine was implemented in 1127 during the “Black Death” in Venice. More recent quarantines occurred in 2003 with the severe acute respiratory syndrome “SARS,” and in 2014 with the “Ebola” outbreaks (Brooks et al., 2020; Gensini et al., 2004). Research indicates that quarantine abiders experienced loneliness, confusion, anger, several medical difficulties (e.g., insomnia, changes in metabolism, fever, hypoxia, and cough); as well as alterations in immune, endocrine, and neurocognitive functioning (de Medeiros Carvalho et al., 2020; Ellis, 2020).

Specifically, social isolation and associated loneliness may act as part of the pathway that leads to the adverse mental health outcomes seen both historically and during the Covid-19 pandemic (Brooks et al., 2020; Gensini et al., 2004; Tyrrell & Williams, 2020; Williams, 2020). A systematic review by Brooks et al. (2020) observed that individuals subject to prior quarantines experienced psychological health effects which included post-traumatic stress symptoms, fear, confusion, boredom, and anger, with some research indicative of long-lasting effects. These findings are similar to those of de Lima et al. (2020) and Wang et al. (2021), which likewise documented symptoms of post-traumatic stress, confusion, and anger among quarantine abiders during COVID-19. Individuals with pre-existing psychological or medical conditions were found to be particularly susceptible to the negative psychological effects associated with quarantine, however, it should be noted that compliance to quarantine restrictions, the ability to maintain usual work, and access to adequate information related to COVID-19, were found to attenuate these mental health issues (Wang et al., 2021).

As social connection is an essential component for human well-being, loneliness associated with both the current pandemic and prior research has been found to disturb both physical and psychological functioning (Holt-Lunstad et al., 2015; Plagg et al., 2020). The physical impact of loneliness has been considered comparable to smoking 15 cigarettes per day (Brody, 2020). The neurological signature of feeling isolated and rejected from one’s group, also shares similar neurological markers to the experience of physical pain (e.g., overlapping activation in the somatosensory cortex, posterior insula, and anterior cingulate cortex); which can serve as an illustration of how intense the experiential reality of isolation during quarantine and imprisonment can become (Eisenberger et al., 2006; Kross et al., 2011).

In particular, elderly individuals who experience heightened feelings of loneliness compared to younger age groups, experienced an exacerbation of these feelings due to Covid-19 social distancing guidelines (Tyrrell & Williams, 2020; Williams, 2020). As observed during both the pandemic and prior research, heightened levels of loneliness can be as deadly as smoking, high blood pressure, or diabetes, and contribute to the rapid development of cognitive decline, increased risk of stroke, and premature death (Holt-Lunstad et al., 2015; Plagg et al., 2020; Tyrrell & Williams, 2020; Williams, 2020). Additionally, during the pandemic the elderly and low income individuals are more likely to experience symptoms of isolation and loneliness in greater levels; while marginalized individuals who may have a limited social network, and therefore lack lifesaving social support in times of distress, are also at an increased risk (Ellis, 2020; McQuaid et al., 2021). It is important to note that within the U.S., racial and ethnic minoritized individuals were disproportionately negatively impacted by the pandemic (Tai et al., 2021). Disparities in the ability to access healthcare coupled with historical structural inequities within the mainstream system has resulted in heightened levels of loneliness, elevated infection and mortality rates among communities of color and low income households in particular (McQuaid et al., 2021; Mein, 2020). In relation to the current manuscript, the overrepresentation of racial and ethnic minoritized individuals observed among prisoner populations, serves to further illustrate the impact of these societal inequities and their disproportionate consequences (Bonner et al., 2017; Cooper et al., 2021).

As in-person treatments and social gatherings to help alleviate the negative feelings brought on by isolation are considered “high-risk” activities during a pandemic, individuals and researchers have begun turning towards various alternative means for managing mental health (Ho et al., 2020), including through the practice of meditation and mindfulness (Polizzi et al., 2020; Yanyu et al., 2020). In summary, the potential negative effects (both the immediate and long-term) experienced during the current coronavirus pandemic are pervasive and likely partially mediated by social isolation. As this is a recent event currently bereft of available longitudinal data, we can draw from prior research with a similar population in order to ascertain the potential long-term consequences of this pandemic. A more nuanced understanding and explanation of these deleterious effects can be gleaned through an examination of a population which had long grappled with a constant experience of the negative medical, physiological, and psychological effects of forced isolation: prisoners.

The Experiences of Isolation in Prison

Isolation during imprisonment exists on a spectrum, with incarceration itself separating the individual from their family, friends, and social network, but allowing interaction with other inmates and prison staff; solitary confinement is the most severe end of the isolation spectrum (Bennett, 2016; Palmer and Connelly, 2005). Solitary confinement is the forced separation and isolation of a prisoner into a desolate cell, located in a secluded and inaccessible section of the prison for a nearly continuous period of time (Haney, 2018); it is implemented among 80,000 to 250,000 prisoners on an annual basis (Reiter et al., 2020). Solitary confinement has been utilized in facilities for years, denying prisoners any social contact with other human beings or any environmental stimulation (Haney, 2018)

The effects of solitary confinement are pervasive and often result in “severe harm to physical and mental health...including increased risk of self-mutilation, suicidal ideation, greater anxiety, depression, sleep disturbance, paranoia, and aggression” (Haney, 2018, p. 368). The exacerbation of any emerging or pre-existing mental illness, as well as trauma symptoms is also common among prisoners who entered incarceration with some initial degree of psychopathology (Kao et al., 2014; Schulz, 2016). In addition, prisoners have reported intrusive thoughts, irrational anger, memory problems, extreme psychological numbness, hallucinations, and perceptual distortions (Haney, 2018). Qualitative studies reveal that individuals who leave solitary confinement tend to withdraw socially from their communities, unable to successfully reintegrate into their social lives (Haney, 2018).

The lockdowns and quarantines observed during the Covid-19 pandemic, likewise exist on a spectrum of severity, with different governments adopting and enforcing guidelines more harshly and severely than others (Shah et al., 2020). For example, in some countries, individuals could still go out to buy essential items, while in other countries individuals were not allowed to leave their apartments. Similar to prisoners, there are some who have the freedom to leave the compound under supervision from authorities, while others, such as those in solitary confinement, are not allowed to leave their cell at all.

An additional overlap between the experience of incarceration and that of quarantine during Covid-19 is the possible post-release stigmatization, which commonly occurs after release from prison and is also observed among those recovered from contagious illnesses. (Gensini et al., 2004). Others are fearful of engaging with former prisoners and those recovered from contagious disease due to fear of recidivism or infection, which leads to further social isolation and increased risk for adverse psychological outcomes (Bagcchi, 2020; Brooks et al., 2020; Nagin et al., 2009).

Although analogous comparisons can be drawn between the experiences of quarantine and prison, it is important to note that differences obviously exist in terms of severity, the actual living space available, the length of time spent in prison, lockdown or quarantine, the lack of freedoms, the amount of possible leisure activities and hobbies, the availability of internet access, social media use, and outdoor natural environments such as parks to freely move around while maintaining social distance from others. In particular, individuals in solitary confinement have no access to any other forms of stimulation or social outlets, let alone the ability to walk into another room. It is for these reasons among others, that some current prisoners and ex-prisoners have written and explained that these situations are not completely comparable (Metcalf, 2020; Schultz, 2020).

We have chosen to focus on prisoners and exclude other individuals who also experience isolation, such as military personnel or astronauts, because they are less comparable to prisoners or those in lockdown or quarantine for two main reasons: 1) These samples choose, of their own volition, their profession and are compensated accordingly. They understand what their job entails and for how long they may be isolated; 2) These samples do not have their situations forced upon them from authorities without their consent, as is the case among prisoners, quarantine abiders and those in lockdown (the strictness and adherence to this enforcement, however, exists on a spectrum and differs by country). For these reasons, comparison with these other samples is not appropriate.

Meditation and Mindfulness as an Intervention

Past empirical research has found meditation and mindfulness to be successful psychological interventions amongst prisoner populations suffering from a diverse array of psychopathologies (e.g., depression, anxiety, insomnia, stress, trauma symptoms, and mood disturbance) and may demonstrate similar efficacy amongst quarantine abiders dealing with similar psychological issues (Ferszt et al., 2015; Himelstein, 2011; KyiBo, 2020; Michaels, 2020; Nidich et al., 2016; Sumter et al., 2009). The practice of meditation and mindfulness has a long historical, religious and cultural past in Eastern civilizations, including China, India, Japan, Thailand, and Tibet (Lutz et al., 2007). More recently, meditation and mindfulness have become popularized in Western societies, albeit in more secular forms, such as Mindfulness-based stress reduction (MBSR), and has received increased attention from the scientific community due to its potential clinical psychological and medical applications (Kabat-Zinn, 2003).

Although various forms of meditation and mindfulness exist, they share key elements, which include the conscious control of an individual’s attention, the regulation of one’s affective response, increased awareness of the present moment, non-judgmental observation, and acceptance of reality as it is (Kabat-Zinn, 2003; Lutz et al., 2007; Lutz et al., 2008; Tang, Holzel & Posner, 2015). Meditation can be conceptualized as a variety of practices developed over millennia to aid individuals in the cultivation of more adaptive cognitive and affective functioning; for the purposes of enhancing positive traits, behaviors, and well-being (Goleman & Davidson, 2017; Lutz, et al., 2007), while mindfulness can be conceptualized as the mental quality of maintaining through conscious awareness, an openness and non-judgmental stance towards one’s thoughts, feelings, sensations, and perceptions (Kabat Zinn, 2003).

It is important to note that more recently, mindfulness has also been conceptualized as a quality of personality, a characteristic trait which individuals are biologically endowed with via genetic and environmental contributions (Baer et al., 2006; Rau & Williams, 2016; Siebelink et al., 2019). As dispositional mindfulness can be enhanced through the practice of different forms of meditation, the current review can glean some of the effects of meditation via the outcomes of higher levels of dispositional mindfulness on psychological well-being and coping during quarantine/lockdown (Baer et al., 2006; Quaglia et al., 2016; Goleman & Davidson, 2017). Due to the difficulty of carrying out true experiments during the current pandemic (i.e., randomly assigning individuals to different meditation interventions), dispositional mindfulness was measured in the majority of the recent studies in order to test for associations with relevant outcomes. Although dispositional mindfulness is not itself a form of meditation, it can be conceptualized as a proxy meditation or MBI being implemented during quarantine or lockdown, and for this reason is included in the review.

It is important to point out that there is evidence suggesting that MBIs, under certain conditions, can lead to psychotic or other psychological symptoms in individuals who are predisposed and who are not adequately prepared or supervised during these practices (Chan-Ob & Boonyanaruthee, 1999; Walsh & Roche, 1979). It should be noted, however, that modified MBIs have also been found to help alleviate the symptoms of individuals experiencing an episode of psychosis, suggesting that the context and appropriate delivery of an intervention plays a key role in determining these differential outcomes (Dyga & Stupak, 2015; Khoury et al., 2013).

Neurobiological Mechanisms of Meditation and Mindfulness

In this paper, we have integrated information about neural networks and physiological variables in order to provide the reader with further evidence as to how meditation and MBIs can alter the brain and physiology, not only relying on self-reported claims of altered mental processes. For example, one of the main difficulties in researching meditation and MBIs is how to explain first person/subjective accounts of meditation experience with third person/objective evidence to substantiate these claims (Verala, 1996). In this way, by providing the reader evidence of neurological and physiological markers of meditation and MBIs, a neurophenomenological account can be presented (Lutz & Thompson, 2003). These structural and functional alterations demonstrate that subjective accounts can be explained and substantiated through objective physical markers elicited through the practice of meditation and MBIs.

Meditation and mindfulness have been associated with increased functional activity in the executive control network, which is involved in cognitive control functions such as attention, conflict monitoring, working memory, and inhibition (Taren et al., 2017); as well as decreased activity in the default mode network which is involved in self-referential processing, rumination, and mind wandering (Brewer et al., 2011). As different meditation practices induce varying effects on underlying neural circuitry, scientific investigation into the neural mechanisms and functional systems specific to each technique is ongoing (Lutz et al., 2007; Tang, Holzel & Posner., 2015). For example, in some instances, meditation increases activation in specific brain regions and networks involved in engaged attention and monitoring (e.g. visual cortex and dorsolateral prefrontal cortex) through the practice of a focused attention (FA) meditation (e.g., focusing on the breath, a candle, mantra, and visualization; Brefczynski-Lewis et al., 2007). Other practices utilizing an open monitoring (OM) meditation (e.g., non-conceptual awareness; Davidson & Lutz, 2008), may deactivate these very same regions when individuals practice an alternative style of mindfulness (e.g., mindful acceptance) in order to reduce pain and emotion (Kober et al., 2019).

Similar to any type of training focused on the development of new skills or habits, overtime, sustained meditation practice can lead to neuroplastic brain changes and connectivity in the form of grey matter density and white matter track alterations, as well as electrical signal oscillatory changes; correlated with enhanced cognitive and affective functioning (Davidson & Lutz, 2008). Posner et al. (2014) theorize that white matter alterations (which improve functional connectivity) occur through an increase in myelination brought about through molecular changes attributed to increased theta wave activity during meditation. Theta waves have been found to be associated with increased positive affect, focus and autonomic nervous system activity (Posner et al., 2014) and have been observed to increase during meditation (Amihai & Kozhevnikov, 2014; Cahn & Polich, 2006). One further theory as to how meditation may increase cortical thickness and functional connectivity is that increased synchronous firing of neurons contributes to strengthening synaptic connectivity and induces neural plastic changes (Lutz et al., 2004). Psychological benefits such as improved attention, emotion regulation, and stress reduction, as well as improved physiological functioning in the form of decreased cortisol levels and reduced biomarkers of inflammation, have been found from even short durations of practice; with longer term practice increaseing these positive effects (Creswell et al., 2012; Davidson et al., 2003; Davidson & Lutz, 2008; Tang et al., 2007).

A review of the literature on meditation as utilized in prison settings, reveals four recurring types of meditation being studied and implemented: Transcendental Meditation (TM), Vipassana Meditation (VM), Mindfulness-based stress reduction (MBSR), and related Mindfulness-based interventions (MBIs; see Table 1 for a summary). A brief overview of each of these methods, along with key neuroscience and clinical findings is presented next in order to help guide the uniformed reader. This is followed by the results section of the current review which contains the literature related to meditation and MBIs amongst prisoners, and those in lockdown or quarantine.

Table 1.

Effects of meditation and mindfulness-based interventions in prison, quarantine, and lockdown.

Results	Effect size	Design	Participants/Sample Size	Meditation	Study
Meditation/Mindfulness in prison
Decreased stress, anxiety, depression and sleep symptoms	t(17) = 2.805, p = 0.012 (Stress) t(17) = 4.079, p = 0.001 (Anxiety) t(17) = 4.228, p = 0.001 (Depression) t(14) = 3.574, p = 0.003 (Sleep)	Compared within subjects pretest-posttest	N = 33 Female prisoners M Age = 34.9	MBI	Ferszt et al. (2015)
Improvements in mindfulness, decreased depression, anxiety, stress and somatoform symptoms	β = –1.56, 95%CI[–2.03, –1.08] p < .001 (Patient Health Questionnaire – Depression subscale) β = 3.04, 95% CI[1.90, 4.18] p < .001 (Acceptance and Action Questionnaire – Version 2) β = 2.28, 95% CI[0.63, 3.97] p < .01 (Mindfulness) β = –1.44, 95% CI [–2.50, –0.38] p < .001 (Depression Anxiety and Stress Scale – Depression subscale) β = –1.76, 95% CI [–2.60, –0.93] p < .001 (Depression Anxiety and Stress Scale – Anxiety subscale) β = –2.02, 95% CI[–2.98, –1.05] p < .001 (Depression Anxiety and Stress Scale – Stress subscale) β = –0.67, 95% CI[–1.08, –0.26] p < .01 (Somatoform symptoms)	Compared within subjects pretest-posttest	N = 59 Female prisoners M Age = 34.7	MBI	Riley et al. (2019)
Somatic symptom complaints	β = −0.32, 95% CI[−0.34, −0.16] p < 0.001	Correlational	N = 209 prisoners (4% Female) M Age = 30.9	Dispositional Mindfulness	Ifeagwazi et al. (2019)
Decreased hostility and mood disturbance, increased self-esteem	Cohen’s d = .23 (Hostility) Cohen’s d = .21 (Self-esteem) Cohen’s d = .41 (Mood)	Compared within subjects pretest-posttest	N = 1,350 prisoners (64% female) M Age = N/A	MBSR	Samuelson et al. (2007)
Decreased stress and anger, increased self-esteem	Cohen’s d = .69 (anger) Cohen’s d = .82 (stress-responsivity) Cohen’s d = .53 (self-esteem)	Compared within subjects pretest-posttest	N = 22 Male prisoners M Age = 40	MBSR	Bouw et al. (2019)
Decreased state and trait anxiety, neuroticism, negativism, suspicion, irritability, hostility, and insomnia	TM Group 1 Vs Control Group 1: F(1,34) = 24.44, p <.05 (Reduced state anxiety) F(1,34) = 13.26, p <.05 (Reduced trait anxiety) F(1,34) = 14.95, p <.05 (Reduced neuroticism) F(1,30) = 17.30, p <.05 (Reduced negativism) F(1,30) = 10.32, p <.05 (Reduced suspicion) F(1,30) = 3.96, p <.058 (Reduced Irritability - Non-significant) F(3,32) = 1.00, p <.01 (Reduced Blood pressure - Non-significant) Z = 3.41, p <.05 (Reduced sleep onset) Z = 2.63, p <.05 (More continuous/less awakenings) Z = 2.92, p <.05 (Improved sleep quality) TM Group 2 Vs Control Group 2: F(1,43) = 17.81, p <.05 (Reduced state anxiety) F(1,43) = 12.70, p <.05 (Reduced trait anxiety) F(1,43) = 11.62, p <.05 (Reduced neuroticism) F(1,43) = 3.09, p <.05 (Extroversion - Non-significant) F(l,39) = 6.99, p <.05 (Reduced assault) F(1,39) = 5.54, p <.05 (Reduced irritability) F(1, 39) = 27.83, p <.05 (Reduced negativism) F(1,39) = 6.22, p <.05 (Reduced resentment) F(l,39 = 9.41, p <.05 (Reduced verbal hostility) Z = 2.04, p <.05 (Reduced sleep onset) Z = 2.04, p <.05 (More continuous/less awakenings) Z = 2.56, p <.05 (Improved sleep quality)	Compared to control group	N = 115 Male prisoners M Age = 60% in 30s, 20% in late 20s, 20% over 40	TM	Abrams and Siegel. (1978)
Decreased stress, anxiety, dissociation, depression, trauma symptoms and sleep disturbance	Cohen’s d = .67 to .89 (on all variables)	Compared to control group	N = 181 Male prisoners M Age = 29	TM	Nidich et al. (2016)
Decreased trauma symptom	Cohen’s d = .65 to .99 (on all variables)	Compared to waitlist control group	N = 22 Female prisoner M Age = 44.5	TM	Nidich et al. (2017)
Decreased stress, anxiety, behavioral issues, and sleep disturbance	Cohen’s d = .47, 95% CI [.10,.85] p = .013 (Psychological well-being)*	Compared to control group	N = 33 Female prisoners M Age = N/A	TM	Sumter et al. (2009)
Decreased psychiatric symptoms, decreased alcohol and substance abuse, improvements in psychosocial functioning	β = −.21 (psychiatric symptoms) β = −.16 to −.26 (alcohol and substance abuse) β = −.12 to .23 (psychosocial functioning)	Compared to treatment as usual control group	N = 173 prisoners (20% female) M Age = 37.5	VM	Bowen et al. (2006)
Decreased anxiety, depression, hostility, and improved psychological and physical health	Cohen’s d = .29, 95% CI[.00,.58] p = .048 (Behavioral functioning)*	Compared within subjects Pretest-posttest (Study 1) Compared to control group (Study 2)	N = 120 Male prisoners (Study 1) M Age = 65% below 30 N = 150 Male prisoners (Study 2) M Age = 70% below 30	VM	Chandiramani et al. (1995)
Decreased mood disturbance, increased mindfulness and emotional intelligence	Cohen’s d = .59, 95% CI[.42, .77] p < .0001 (Psychological well-being)*	Compared to alternative-treatment control	N = 127 Male prisoners M Age = 35.4	VM	Perelman et al. (2012)
Decreased substance use	F(5, 80) = 5.00, p < .001, adjusted R2= .20 (Decreased drinking after 3 months) F(5, 65) = 4.79, p < .001, adjusted χ2 = .23. (Decreased illicit drug use after 3 months)	Compared to treatment as usual control group	N = 303 prisoners (33% female) M Age = 37.6	VM	Simpson et al. (2007)
Meditation/Mindfulness in quarantine and lockdown
Decreased psychological distress	β = −.504 (Global Severity Index)	Correlational	N = 6,412 (25% male) M Age = 32.7% under 30, 40.1% 30-50, 27.2% over 50	Dispositional Mindfulness	Conversano et al. (2020)
Overall mindfulness predicted lower anxiety and depression	β = −.06, SE = .03, t = −1.98 (p < .05) β = −.12, SE = .03, t = −3.44 (p < .000)	Correlational	N = 402 (37% female)	Dispositional Mindfulness	Dubey et al. (2020)
			M Age = 61.9% 18-29, 28.1% 30-39, 5.4% 40-49, 2.9% 50-59, 1.4% 60+
Increased engagement in COVID-19 preventative health measures	F(16, 334) = 6.96, p < .001 (R2Δ = 0.25, p < .001) β = 0.17 (p = .02) (increased social distancing)	Correlational	N = 353 (59.8% female) M Age = 41.4	Dispositional Mindfulness	Haliwa et al. (2020)
Decreased hopelessness	β = − .128, 95% CI[−.160, −.096] (p < .001) (Direct effect of mindfulness on hopelessness	Correlational	N = 786 (28.4% males) M Age = 24	Dispositional Mindfulness	Saricali et al. (2020)
Decreased anxiety	β = − 0.22, (p = 0.002)	Correlational	N = 170 (73.5% female) M Age = 27.8	Dispositional Mindfulness	Wielgus et al. (2020)
Decreased stress, anxiety and depression, higher levels of self-kindness	r = −.465, p < .05 (Stress) r = −.468, p <.05 (Anxiety) r = −.552, p <.05 (Depression) M = 6.28, SD = 1.55 vs. M = 7.09, SD = 1.92, d = 0.50, (p = 0.001) (Self-kindness level between none and mindfulness) M = 6.28, SD = 1.55 vs. M = 7.62, SD = 2.18, d = 0.85, (p = 0.002) (Self-kindness level between none and TM)	Correlational	N = 412 (84.5% female) M Age= 40.5	Dispositional Mindfulness, VM, TM, Zen, MBI	Jiménez et al. (2020)
Improvements in subjective measures of negative emotion, positive emotion, depressive symptoms, anxious symptoms, loneliness, healthy and unhealthy behavior	β = −.09, 95% CI[−.12, −.06] (Mindfulness and negative emotion) β = .19, 95% CI[.16,.22] (Mindfulness and positive emotion) β = −.06, 95% CI[−.08, −.03] (Mindfulness and depressive symptoms) β = −.05, 95% CI[−.08, −.02] (Mindfulness and anxious symptoms) β = .06, 95% CI[.03,.09] (Mindfulness and loneliness) β = .06, 95% CI[.03,.09] (Mindfulness and healthy behavior) β = .05, 95% CI[.01,.08] (Mindfulness and unhealthy behaviors) (All p < .01)	Correlational	N = 5,115 (75% female) M Age = 21.3	Dispositional Mindfulness	Sweeny et al. (2020)
Decreased anxiety, depression, emotional exhaustion and increased affective empathy, psychological well-being, interoceptive awareness, and mindfulness levels	F(1,56) = 9.7, p = 0.003, ηP2 = 0.303 (Increased mindfulness) F(1,56) = 9.9, p = 0.003, ηP2 = 0.150 (Increased affective empathy in low resiliency group) F(1,56) = 8.2, p = 0.006, ηP2 = 0.128; F(1,56) = 9.0, p = 0.004, ηP2 = 0.138 (Increased interoceptive awareness in high and low resiliency groups) F(1,56) > 5.8, p < 0.02, ηP2 > 0.109 (Improved psychological well-being) F(1,56) = 8.7, p = 0.005, ηP2 = 0.135 (Decreased anxiety) F(1,56) = 13.8, p < 0.001, ηP2 = 0.198 (Decreased depression) F(1,56) = 6.7, p = 0.01, ηP2 = 0.108 (Decreased emotional exhaustion)	Compared within subjects pretest-posttest and between subjects (high and low resilience groups)	N = 66 females M Age = 51.5	MBI	Matiz et al. (2020)
Decreased stress	F[2,237] = 3.6, p = .03, ηP2 = .03 (Square breathing and body scan decreased stress)	Compared to 2 active control groups	N = 294 (26.5% male)	MBI	Pizzoli et al. (2020)
Increased sleep duration and mindfulness	β = 0.29, SE = 0.12, p = 0.02 (increased mindfulness: Study 1) β = 0.05, SE = 0.03, p = 0.046 (Sleep duration: Study 1) β = 0.11, SE = 0.05, p = 0.04 (Interaction effect of Mindfulness and Covid-19 stressors on sleep quantity: Study 2)	Randomized controlled trial	N = 97 (68% female) (study 1) M Age = 34.5 N= 140 (59.3% female) (study 2) M Age = 34.1	MBI	Zheng et al. (2020)
Increased self-compassion, decreased perceived stress, decreased emotional eating	η2 = 0.117 (Self-compassion) η2 = 0.094 (Perceived stress) η2 = 0.111 (Emotional eating)	Compared to waitlist control group	N = 57 (48 females) M Age = 29	Compassion meditation	Schnepper et al. (2020)

Note. LKM = loving-kindness meditation; MBSR = mindfulness-based stress reduction; MBI = mindfulness-based interventions; TM = transcendental meditation; VM = vipassana meditation.

*Effect sizes extracted from Auty, Cope and Liebling (2017).

Transcendental Meditation

TM is a method of meditation which stemmed out of ancient South Asian yogic practices. It utilizes the mental repetition of a mantra (sacred Sanskrit syllables and words imbued with various meanings) to focus, calm down, and allow the mind to reach a subtle and transcendental state of being; individuals generally practice 20 minute sessions, twice a day, seated upright with their eyes closed (Roth, 1994).

TM Neuroscience Findings. Neuroscientific research into the brain systems involved in the accompanying physiological alterations which occur during TM practice have found increased BOLD (Blood oxygen level dependent) signal activation in the dorsolateral prefrontal cortex (involved in attention) and the anterior cingulate cortex (involved in conflict monitoring and executive function) along with deactivation in the pons and cerebellum (areas involved in arousal) amongst long-term TM meditators (Mahone et al., 2018). Although TM practice utilizes a silent mantra to direct attention, EEG (Electroencephalography) studies have not found an increase in gamma oscillations, which has been observed during other types of meditation involved in focused attention; this suggests that TM has unique effects on brain connectivity and activation (Travis & Parim, 2017). A meta-analysis of the physiological effects of TM found that consistent practice resulted in decreased systolic (highest BP reading) and diastolic (lowest BP reading) blood pressure (BP) amongst 851 participants with cardiovascular disease (Gathright et al., 2019). Additionally, another study found that consistent TM practice resulted in decreased salivary cortisol levels (associated with stress levels), compared to a control group after an 8-week trial; this suggests TM practice can elicit a modulation of hypothalamic-pituitary-adrenal (HPA) axis activity, which is likewise associated with stress response (Klimes-Dougan et al., 2020).

Vipassana Meditation

Vipassana is a style of meditation mainly practiced in Southeast Asian countries such as Thailand, Vietnam, Burma, and Cambodia. Its roots began in the early teachings of Theravada Buddhism and now forms the basis of many modern styles of mindfulness practice. Vipassana, a Pāli word meaning “insight,” refers to the ability to clearly understand the nature of reality and one’s mind (Hart, 2011). The path of meditation in vipassana generally begins with a 10-day silent retreat in an isolated environment, in which practitioners sit upright with their legs crossed and their eyes half closed, directing their attention to their breath in order to calm down and focus their mind. Gradually, their mind progresses into increasingly subtle, calm, and aware dimensions of consciousness (Buddhaghosa, 1991) which promotes an understanding of one’s mental processes, as well as the ability to release thoughts and attachments (Hart, 2011). Ideally, meditators learn to relinquish their maladaptive habitual tendencies, attain equanimity, and eradicate their personal suffering to reach “nibbana,” a complete freedom from all forms of suffering (Bhikkhu, 1993; Chavan, 2007).

VM Neuroscience Findings. Vipassana can be seen as a psychological method for increasing metacognition: the introspective awareness of one’s thought processes and feelings, along with the heightened ability to self-regulate subsequent behavior in a more adaptive fashion (Dorjee, 2016). Neuroscientific studies of long-term vipassana meditators have found decreased amygdala reactivity to emotional stimuli, attributable to the development of enhanced control of attentional and executive function abilities (Kral et al., 2018). Vipassana has also been associated with increased self-regulation of emotional and behavioral responses that leads to decreased stress reactivity corresponding to the development of increased ability for self-directed attention (Kral et al., 2018).

Rosencranz and colleagues (2016) found that experienced Vipassana meditators showed less quantifiable biomarkers of stress in the forms of decreased cortisol and decreased neurogenic inflammatory response, while also reporting less subjective stress after exposure to social stress (Rosencranz et al., 2016). Krygier et al. (2013) likewise observed improved biomarkers in the form of increased high frequency heart rate variability (HF HRV), among a group of vipassana meditators following the completion of a 10-day retreat.

Lastly, a study implementing electroencephalography (EEG) of vipassana meditators, found increased parieto-occipital gamma power, related to heightened sensory awareness, during the practice of meditation; thought to be a reflection of meditative prowess (Cahn & Polich, 2006; Cahn et al., 2010).

Mindfulness-Based Stress Reduction

Mindfulness-based stress reduction (MBSR) was developed in 1979 at the University of Massachusetts Medical Center by Jon Kabat-Zinn as a secular meditation training method derived from Buddhist meditative practice. MBSR was originally intended to be applied as a complementary form of therapy amongst heterogeneous clinical populations grappling with various illnesses, stressors, and pain (Kabat-Zinn, 2003). MBSR consists of an 8 week training program which includes mindfulness meditation, body scans, and physical yoga (Kabat-Zinn, 2013). According to Kabat-Zinn, the key aspect of MBSR, “mindfulness,” can be operationally defined as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment (Kabat-Zinn, 2003, para. 5).” The sustained cultivation of this type of attentional stance throughout an individual’s daily activities leads to increased awareness of mental and physical processes along with the ability to accept and let go of maladaptive cognitive-emotional patterns which may be contributing to the individual’s stress, pain, and anxiety (Kabat-Zinn, 2003).

MBSR Neuroscience Findings. Numerous studies and meta-analysis have been conducted investigating the clinical efficacy and neurological mechanisms of MBSR on various pathologies (for reviews see, Chiesa & Serretti, 2009; Grossman et al., 2004; Khoury et al., 2015). Two key studies of non-prisoner populations find that after an 8-week MBSR course, there is increased activity in left-sided anterior brain regions (an area associated with positive affect), a significant increase in influenza vaccine antibody titers, which is associated with heightened immune function, decreased feelings of subjective loneliness, and downregulation of associated pro-inflammatory NF-κB-related gene expression of circulating leukocytes (Creswell et al., 2012; Davidson et al., 2003). These studies support MBSR’s ability to mitigate feelings of loneliness and maladaptive physiological responses.

Related Mindfulness-based Interventions

There are a few noteworthy studies which have utilized MBIs derived from MBSR in prison settings and most recently, in quarantine during the Covid-19 pandemic. MBIs emerged from MBSR and consist of interventions which utilize key aspects of mindfulness-based meditation (Cullen, 2011). Related practices for stress reduction include Loving-kindness meditation (LKM). Studies on non-prisoner populations have found MBIs to be effective for alleviating pain and negative emotions (Kober et al., 2019; Zeidan et al., 2012), decreasing stress, increasing self-compassion and mindfulness (Flett et al., 2019), and increasing feelings of social connection and positivity (Hutcherson et al., 2008).

Current Review

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guided the current narrative review (Liberati et al., 2009). Using a select number of search terms, the current manuscript systematically reviewed the literature on a range of meditation interventions for prisoners and individuals in quarantine or lockdown, with the goal of summarizing the findings and drawing research-based recommendations for the application of these practices during the current pandemic.

Methods

Eligibility Criteria

Studies were included in the review if the intervention was based on a type of meditation or mindfulness practiced in prison, quarantine, or lockdown (other modalities that involve meditation as one component were excluded, e.g., physical yoga, chi gong, and tai chi were excluded). Studies which assessed dispositional/trait-like mindfulness were included. All geographical locations were included in order to increase the generalizability of the findings. Papers were excluded from the primary count if the abstract did not relate to the topic of this manuscript, if it was not written or translated into English, if it was a review paper, meta-analysis, or if the methodology was not clearly elucidated enough to determine its cogency. The PRISMA Flow Diagram template was used for the construction of the current review’s flow diagram (Liberati et al., 2009; See Figure 2). As study designs varied and were limited in extent, both those with and without a control or comparison group were included.

Information Sources, Search Strategy and Selection Process

From April to December 2020, Pubmed and Google Scholar were used to search for peer reviewed empirical manuscripts ranging from the earliest prison-meditation studies (conducted in the 1970s) to the most recent pandemic quarantine/lockdown meditation and mindfulness studies conducted in 2020. Two reviewers, MB and MK, independently searched, screened and assessed relevant articles based on the set search term criteria (e.g., “meditation,” “prison,” “quarantine,” “mindfulness,” and “Covid-19”). When the first search was complete, MB did a final search in order to confirm that no papers were missed.

Data Collection Process and Data Items

Data was extracted from the articles by MB and AI, imputed into spreadsheets and finally into the tables. Data items included the following: study title, authors, year, age and sex of participants, intervention type, setting (e.g., quarantine, lockdown, prison, and laboratory), study design, outcomes, and when possible, effect sizes, confidence intervals, and p-values. The field of meditation research investigates numerous types of outcome variables based on psychological, physiological, and cognitive measures. This review focused primarily on outcomes related to psychological functioning in the context of meditation and mindfulness in prison, quarantine, and lockdown. These include depression, anxiety, stress, insomnia, somatic symptoms, maladaptive behaviors, well-being, emotional processing, and mindfulness.

Study Risk of Bias Assessment

Bias was assessed using the Cochrane Risk of Bias Tool; which includes assessments of selection bias, allocation bias, performance bias, detection bias, attrition bias, reporting bias, and an other category which included reported conflicts of interest and self-reported biases (Higgins et al., 2011; See Table 2 for details on the individual studies). The ratings ranged from low (−), high (+), or unclear (?) risk of bias. A final column was added to give an overall Risk of Bias rating for each study. AI and MB independently assessed each paper for bias, rated, and then discussed each to resolve any discrepancies until consensus was met and a final rating was determined.

Table 2.

Risk of Bias Assessment.

Bias Study	Random Sequence Generation (Selection Bias)	Allocation Concealment (Selection Bias)	Blinding of Participants and Personnel (Performance Bias)	Blinding of Outcome Assessment (Detection Bias)	Incomplete Outcome Bias (Attrition Bias)	Selective Reporting (Reporting Bias)	Other Bias	Overall Bias Rating
Ferszt et al. (2015)	(+)	(?)	(+)	(?)	(+)	(−)	(+)	High
Riley et al. (2019)	(+)	(?)	(?)	(?)	(−)	(−)	(−)	Unclear
Bouw et al. (2019)	(−)	(?)	(?)	(?)	(?)	(+)	(+)	Unclear
Samuelson et al. (2007)	(+)	(?)	(+)	(?)	(+)	(−)	(+)	High
Abrams & Siegel (1978)	(?)	(?)	(+)	(?)	(+)	(+)	(+)	High
Ifeagwazi et al. (2019)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Nidich et al. (2016)	(−)	(?)	(+)	(?)	(−)	(−)	(+)	Unclear
Nidich (2017)	(−)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Sumter et al. (2009)	(+)	(?)	(?)	(?)	(−)	(−)	(−)	Unclear
Bowen et al. (2006)	(+)	(?)	(+)	(?)	(−)	(−)	(−)	Unclear
Chandiramani et al. (1995)	(−)	(+)	(+)	(?)	(+)	(−)	(−)	Unclear
Perelman et al. (2012)	(?)	(?)	(+)	(?)	(+)	(−)	(−)	Unclear
Simpson et al. (2007)	(+)	(+)	(?)	(?)	(−)	(−)	(−)	Unclear
Conversano et al. (2020)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Dubey et al. (2020)	(−)	(−)	(?)	(?)	(−)	(−)	(+)	Low
Haliwa et al. (2020)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Saricali et al. (2020)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Wielgus et al. (2020)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Jiménez et al. (2020)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear
Matiz et al. (2020)	(+)	(?)	(?)	(?)	(?)	(−)	(−)	Unclear
Pizzoli et al. (2020)	(−)	(?)	(?)	(?)	(−)	(−)	(−)	Low
Zheng et al. (2020)	(−)	(−)	(−)	(−)	(−)	(−)	(+)	Low
Schnepper et al. (2020)	(−)	(?)	(?)	(?)	(−)	(−)	(−)	Low
Sweeny et al. (2020)	(+)	(?)	(?)	(?)	(−)	(−)	(+)	Unclear

Note. Tabular representation of risk of bias in individual studies. The authors of this systematic review on the efficacy of meditation and mindfulness-based interventions for individuals in quarantine used the Cochrane “risk of bias” tool in order to ascertain potential sources of bias included in the studies. Ratings ranged from low (−), high (+), or unclear (?) risk of bias.

Effect Measures

Outcomes varied and were measured based on mean differences within subjects, between subjects, changes in regression slopes, and strength and direction of correlation coefficients. Effect measures included Cohen’s d, Hedge’s g, Standardized β, r, η2, ηP², F ratios, t values, $\chi 2$, Z-standard scores, Confidence Intervals, and p-values (when available). When no effect size was reported in a study, but enough information was available for a computation, MB calculated the effect size and reported it in Table 1. Other precalculated effect sizes were extracted from a systematic review by (Auty et al., 2017).

Synthesis methods

Studies which met inclusion criteria were grouped based on two main characterizations in order to increase the clarity of the review. First, studies were sorted based on the type of meditation intervention. This yielded four main categories: Transcendental Meditation (TM); Vipassana Meditation (VM); Mindfulness-based stress reduction (MBSR); and Mindfulness-based interventions (MBIs). For the purposes of this review, MBIs was composed of related practices such as Loving-kindness meditation (LKM), mindfulness-based guided meditation apps, and studies which assessed Dispositional Mindfulness. Second, subcategories were placed within each of the four main categories: clinical findings among prisoner populations; and clinical findings among individuals in quarantine or lockdown (when these studies were available for that particular category). As this is not a meta-analysis, statistically handling missing data, performing data conversions and related analysis was not necessitated. Summary statistics of each study were tabulated in Table 1 and bias assessments were tabulated in Table 2. After tabulation, each study was compared, sorted, and synthesized into its respective group. Main study characteristics (participants’ characteristics, sample size, intervention, design, and main findings) are described in the review. Effect sizes, confidence intervals, p-values, and age ranges are found in Table 1.

Certainty Assessment

Evidence regarding the certainty or level of confidence in the findings of each study was assessed based on the reporting of a statistical confidence interval when available, and at the minimum, a reported p-value. The usual confidence level reported in studies was 95%. Studies which reported effect sizes along with confidence intervals and/or p-values, and also had a “low” risk of bias, were considered to possess the strongest certainty as to the validity of their findings. Those with “high” risk of bias and lack of reported confidence intervals and/or p-values were considered to possess the weakest certainty as to the validity of their findings.

Results

Study Selection

221 articles were identified based on the selected search terms as being related to the current review. After removing duplicates and screening based on inclusion and exclusion criteria, 24 articles were ultimately included in the manuscript (See PRISMA Flow Diagram Figure 1 for details).

Figure 1.

Flow chart.

TM Clinical Findings Amongst Prisoners

In terms of clinical findings related to psychopathological symptomatology amongst prisoners utilizing TM, an early study by Abrams and Siegel (1978) found improved symptoms of anxiety, neuroticism, hostility, and insomnia amongst the TM group compared to the control. More recently, Nidich et al. (2016), likewise found improved symptoms of anxiety and sleep disturbance, as well as decreased stress, dissociation, depression, and trauma symptoms amongst the meditation group after the TM intervention. Nidich et al. (2017) found improvements in trauma symptoms among a small sample of women prisoners, such as decreased hyperarousal and intrusive thoughts, after 4 months of 20 minute TM sessions twice a day. An earlier study by Sumter et al. (2009) implemented a TM intervention among women prisoners and found improvements in sleep, decreased symptoms of stress and anxiety, increased optimism regarding the future, as well as reductions in maladaptive behaviors such as nail biting and violent behaviors.

The aforementioned findings of TM practice amongst clinical populations and prisoners suggest that TM can be a useful way to decrease psychopathological symptoms, improve physiological functioning, and promote psychological well-being. If practiced by individuals who are isolated at home or have been placed in quarantine during the pandemic, the beneficial effects of TM may help them cope and thrive throughout the duration of the quarantine (For a comprehensive overview of the benefits of TM in the context of prison, see Hawkins, 2003; for a review of TM health benefits more generally, see Walton et al., 2004).

VM Clinical Findings Amongst Prisoners

Vipassana has been implemented amongst prisoner populations as early as 1970; however, research on its efficacy for counteracting psychopathology and maladaptive behaviors has been limited. Despite this limitation, the studies that are available shed light on the potential ameliorating effects of vipassana on various psychopathological symptoms and behavioral outcomes among prisoners.

Bowen et al. (2006) observed a decrease in psychiatric symptoms, decreased alcohol and substance abuse, and improvements in psychosocial functioning following the completion of a vipassana course. A subsequent study corroborated these findings; Simpson et al. (2007) also found a decrease in substance use in prisoners after a vipassana course. Research has also found decreases in anxiety, depression, and hostility, along with improvements in psychological and physical health after the completion of the standard 10-day vipassana course (Chandiramani et al., 1995). These findings have also been supported by longitudinal research. A study by Perelman et al. (2012) following prisoners for 1 year found that prisoners who had practiced vipassana showed decreased mood disturbance, increased mindfulness skills, and higher emotional intelligence.

In summary, the benefits of vipassana meditation are supported by preliminary neuroscientific and psychophysiological evidence of alterations in adaptive functioning associated with the practice. The few studies investigating the effects of vipassana meditation amongst prisoner populations have found vipassana to be efficacious for reducing substance abuse and psychiatric symptomatology, while also improving psychological and physical well-being. These studies suggest that vipassana may be well suited for use among quarantine abiders struggling with substance use or an exacerbation of their psychiatric symptoms.

MBSR Key Clinical Findings Amongst Prisoners

Although few studies have been carried out utilizing MBSR interventions in prison settings, preliminary studies have found MBSR to be effective for improving mood, increasing self-esteem, and decreasing negative emotions (Bouw et al., 2019; Samuelson et al., 2007). For the sake of brevity and due to the paucity of existing empirical studies specifically utilizing MBSR, only two relevant studies are reviewed.

Samuelson et al. (2007) examined the effects of an MBSR intervention among 1,350 prisoners. After completion of the course, prisoners showed improvements in feelings of hostility, mood-disturbance, and self-esteem. The findings suggest MBSR to be an effective treatment for prisoners. Recently, Bouw et al. (2019) conducted a small mixed methods study on Dutch prisoners. Results of the study found improvements in prisoners' self-esteem, stress-responsivity, style of coping, impulse control, as well as decreased aggression following the completion of the course. The study also found that prisoners were satisfied with the MBSR practices, further substantiating the benefits of utilizing MBSR in stressful and isolated settings, particularly relevant and applicable to the situation experienced during a quarantine.

MBIs Findings Amongst Prisoners

Ferszt et al. (2015) implemented an MBI among 33 women prisoners who were not currently using pharmacological treatments. The mindfulness-based meditation practice was shown to alleviate symptoms of stress, anxiety, and depression while also improving quality of sleep (Ferszt et al., 2015). Riley et al. (2019) likewise found improvements in stress, anxiety, depression, somatoform symptoms, and mindfulness among 59 female prisoners using an MBI. Most recently, a Nigerian study by Ifeagwazi et al. (2019) also observed improvements in somatic symptoms among a sample of 209 prisoners who were higher in dispositional mindfulness.

MBIs/Dispositional Mindfulness Findings in Quarantine and Lockdown

Out of the 11 studies conducted in quarantine and lockdown, seven of these assessed dispositional mindfulness. As a reminder to the reader, the majority of the studies which follow are not interventions, but are assessments of the effects of trait-like mindfulness (e.g., dispositional mindfulness) on relevant psychological and behavioral outcomes.

Most recently, an online study of 5,115 quarantine abiders in Wuhan, China by Sweeny et al. (2020), investigated associations between various levels of dispositional mindfulness and “flow” with related psychological and behavioral outcomes during the Covid-19 outbreak. Dispositional mindfulness in this context refers to how much an individual non-judgmentally observes and is aware of the present moment, while “flow” refers to a mode of concentration which is so highly focused that it completely absorbs a person into their current activity and allows for the experience of the swift passage of time (Csikszentmihalyi, 1990). Results of the study found increased levels of mindfulness and flow to be predictors of increased measures of overall well-being; however, “flow” rather than mindfulness was found to be the key moderator between the duration of quarantine and subjective feelings of well-being (Sweeny et al., 2020). Contemporaneously, between February and March of 2020 during the beginning of quarantine and lockdowns in Wuhan, Zheng et al. (2020) carried out a randomized controlled trial of 97 participants in order to ascertain whether practicing mindfulness can mitigate the effects of Covid-19 related stressors on sleep duration and work engagement. Participants were divided into a daily mindfulness practice or a mind wandering control condition with measurements of their sleep duration and level of mindfulness collected. The study found that increased mindfulness contributed to increased sleep duration and mindfulness among the participants in the daily mindfulness practice group (Zheng et al., 2020). In June, of 2020, a second study was conducted in England by Zheng et al. (2020) again testing the effects of mindfulness on sleep quantity, and found comparable results among the 140 participants (i.e., mindfulness diminished the effects of stress due to Covid-19, which in turn improved sleep quantity).

Three studies conducted in Italy during the most severe days of the Pandemic provide insight into the utility of MBIs during Covid-19. Conversano et al. (2020) likewise measured dispositional mindfulness and psychological distress among 6,412 Italian participants in lockdown, via an online survey administered between March and April of 2020 (during the early days of the pandemic). The study found decreased levels of psychological distress among individuals who were higher in dispositional mindfulness, and observed that mindfulness was the best predictor of overall psychological distress and well-being during the pandemic (Conversano et al., 2020). In another study conducted in Italy during the lockdowns, Matiz et al. (2020) conducted an MBI among 66 female teachers and found decreases in anxiety, depression, and emotional exhaustion, as well as improvements in affective empathy, psychological well-being, interoceptive awareness, and mindfulness. The study concluded that MBIs can help alleviate the negative psychological responses observed during the pandemic, especially among the most vulnerable members of society (Matiz et al., 2020). The third study from Italy was a randomized controlled experiment by Pizzoli et al. (2020) which sought to investigate whether guided audio meditation apps administered during the pandemic could alleviate the side-effects attributed to lockdown. In particular, the study compared a guided “square breathing” exercise, to a guided body scan exercise, and a natural sound control group; and found that both the square breathing and body scan decreased stress compared to the natural sounds only group (Pizzoli et al., 2020). The breathing exercise and guided body scan can be considered a MBI since they derive from their relaxation and concentration aspects.

In May of 2020, during a period of strict lockdown in India, Dubey et al. (2020) conducted an online study consisting of 402 Indian participants. The study found that an individual’s overall level of mindfulness predicted lower levels of anxiety and depression among the sample, as well as increased knowledge related to Covid-19; and concluded that MBIs implemented during the pandemic may be beneficial for mental health (Dubey et al., 2020). An online survey of 353 participants conducted across the U.S. in April of 2020 found that individuals with higher levels of dispositional mindfulness showed increased engagement in Covid-19 preventative health measures, particularly increased social distancing (Haliwa et al., 2020). In October of 2020, Saricali et al. (2020) conducted an online survey of 786 participants from 71 cities in Turkey and analyzed the data using structural equation modeling. The model found a direct effect of mindfulness on hopelessness, such that increased levels of mindful awareness decreased the level of hopelessness among participants (Saricali et al., 2020). A negative association was also found between greater fear of Covid-19 and lower levels of mindfulness, which in turn, was related to hopelessness; suggesting that mindfulness mediates the relationship (Saricali et al., 2020). A path analysis conducted by Wieglus et al. (2020) via an online survey of 170 individuals during lockdown in Poland, observed a direct decrease in anxiety among individuals higher in mindfulness, and concluded that mindfulness along with psychological flexibility acts to mediate the relationship between overall well-being and the arising of psychopathology.

Jiménez et al. (2020) conducted a cross-sectional study of 412 individuals from Spain during quarantine between April and May of 2020, taking measures of dispositional mindfulness as well as data on whether individuals practiced any type of meditation (e.g., participants in the study practiced VM, TM, Zen, and MBIs). Overall, the study found decreased stress, anxiety, depression as well as higher levels of self-kindness to be associated with dispositional mindfulness and the other types of meditation (Jiménez et al., 2020). In particular, there were significant differences found between measures of self-kindness and whether individuals practiced mindfulness or TM, compared to none at all; self-kindness was higher among the mindfulness and TM participants (Jiménez et al., 2020). The study, however, concluded that meditation did not act as a protective factor in itself; rather self-compassion, which is closely associated with meditation, may act as an important protective factor during quarantine.

The final study conducted by Schnepper et al. (2020) took place between March and May of 2020 during the increasing lockdowns in Austria and Germany; and utilized a compassion meditation smartphone app compared to a waitlist control group among 57 participants. The study sought to understand whether increased self-compassion (through the use of the compassion meditation app) would contribute to decreased stress and emotional eating. Schnepper et al. (2020) found that compared to the waitlist control group, the compassion meditation intervention led to increased levels of self-compassion, decreased levels of perceived stress and decreased emotional eating during lockdown.

In summary, although most of the “meditation in prison” and “quarantine/lockdown” studies thus far have not been able to maintain the methodological rigor of a controlled laboratory environment (as all of the studies were conducted in actual prison settings or quarantine or lockdown settings uncontrolled by the research teams), they do possess strong external ecological validity due to their real-world application (Andrade, 2018). In particular, the studies conducted by Sweeny et al. (2020) and Zheng et al. (2020) have the strongest external validity. As their studies were conducted during the initial outbreak of the actual Covid-19 pandemic amongst quarantine abiders in Wuhan, they provide clear analogous support for this paper’s overarching theory. Further, the studies on meditation, MBIs and dispositional mindfulness during lockdown in Italy (Conversano et al., 2020; Matiz et al., 2020; Pizzoli et al., 2020), India (Dubey, Podder & Pandey., 2020), the U.S. (Haliwa et al., 2020), Turkey (Saricali et al., 2020), Poland (Wieglus et al., 2020), Spain (Jiménez et al., 2020), Austria, and Germany (Schnepper et al., 2020) provide strong evidence for the utility of meditation and MBIs as global public health interventions during the pandemic. As the studies assessing dispositional mindfulness demonstrate, higher dispositional mindfulness is associated with higher levels of well-being for individuals in prison, lockdown and quarantine, providing further support for the use of meditation to enhance these mindful traits. Based on the sample sizes of the larger studies, these studies provide strong evidence for the beneficial effects of meditation and MBIs for helping cope with time spent isolated in quarantine or lockdown during the pandemic.

Results of Individual Studies/Effect Size

In accordance with Cohen’s conventions for interpreting effect sizes (Cohen, 1988), we find that among the prison studies, effect sizes ranged from small to large. The majority of effect sizes, however, were moderate to large (Cohen’s d ranging from 0.21 to 0.99). In particular, large effects on stress, anxiety, and trauma symptoms were observed. A different pattern of effects were observed among the quarantine and lockdown studies. Effect sizes were less varied and likewise ranged from small to marginally large effects (β ranging from 0.05 to 0.54). The majority of the effect sizes for the MBIs (excluding dispositional mindfulness studies), however, were small and did not pass the moderate range. Small effects were observed on anxiety, depression, mindfulness, and sleep. Details pertaining to the effect sizes for each study included in the review can be found in Table 1.

Risk of Bias and Quality of Studies

The quality of studies was determined by the risk of bias present and was given overall ratings of “Low,” “High” or “Unclear.” “Low” overall ratings indicate that the risk of bias is low and the overall quality of the study was considered to be high. “High” overall ratings indicate that the risk of bias is high and the overall quality of the study was considered to be low. “Unclear” overall ratings indicate that not enough information was available to make an adequate judgment for assessment and the overall quality is uncertain. Of the prison, quarantine and lockdown studies included in the review, four were classified as having a “low” risk of bias, 17 were classified as having an “unclear” risk of bias, and three were classified as having a “high” risk of bias. The majority of “high” risk of bias and unclear risk of bias were those conducted in prisons. These findings make sense, as it is difficult to control many aspects of a study being carried out in an actual prison setting. The majority of quarantine and lockdown studies were rated as either “unclear” or “low” risk of bias. Interestingly, none were found to be “high” risk. (See Table 2 for details of individual studies). Based on the findings from the bias risk assessment, it appears that the recent studies conducted in lockdown and quarantine are relatively high in quality and less biased in their findings compared to the majority of the prison studies. Future studies may wish to explore the reasons behind these differences further, helping shed light on potential ways to reduce bias in this type of research.

Certainty of Evidence

Based on the current reviews criteria for evaluating the certainty of the study outcomes, which consists of the presence or absence of reported confidence intervals, p-values and risk of bias rating; the studies which can be considered to possess the most certainly regarding their outcomes are those of Dubey et al. (2020); Pizzoli et al. (2020); Schnepper et al. (2020); and Zheng et al. (2020). The studies which possessed the least evidence as to the certainty of their findings were those of Abrams and Siegel (1978); Ferszt et al. (2015); and Samuelson et al. (2007). Lastly, 14 of the 24 studies in the manuscript used random assignment to conditions. Random assignment can mitigate the impact of confounding variables by distributing the confounds among the experimental and control groups equally, in turn, strengthening internal validity. As such, more than half of the studies possess relatively strong internal validity.

Discussion

Clinical Implications. In terms of its viability and clinical implications, the practice of meditation and MBIs have been found to be effective for alleviating stress and trauma symptoms amongst prisoners whose experience of psychopathology and loneliness, mirrors that of the psychopathologies found to disturb those in quarantine (Nidich et al., 2016). Dunn (2010) proposed that due to the brain’s neuroplasticity, meditation implemented in prison can lead to positive psychological and behavioral transformations, which, in turn, enables prisoners to transform their brain and mind to function more adaptively. For example, Fleet Maull, who served 25 years in prison, reported that his experience in prison dramatically changed “after years of training [his] mind through daily meditation and intensive retreat practice” (Maull, 2017, para. 6) and explained that meditation provided him with a way to transform his negative feelings into an overarching experience of well-being (Maull, 2017, para. 8). Death row inmate Jarvis Masters, imprisoned in San Quentin for more than 30 years, stated, “You’re either going to go crazy, or kill yourself; One time when I was first meditating, it came to me: I can’t climb the walls, but I can make them disappear” (Moon, 2007, para. 19-20). This transformative type of experience gained through meditation, may also be applicable to individuals during quarantine.

Research on meditation and mindfulness as utilized in prisons has found various styles (e.g., TM, Vipassana, MBSR, MBIs) to be beneficial for reducing a diverse array of psychopathologies, maladaptive behaviors, and improving overall well-being. Recent studies from the current Covid-19 pandemic in lockdown and quarantine settings have also demonstrated evidence in support of the psychological benefits of utilizing meditation and MBIs. For individuals suffering from anxiety, MBIs (Ferszt et al., 2015; Matiz et al., 2020; Riley et al., 2019) TM (Abrams & Siegel, 1978; Nidich et al., 2016; Sumter et al., 2009) and Vipassana (Chandiramani et al., 1995) were found to be effective in reducing symptoms. For depression, MBIs were found to be particularly effective (Ferszt et al., 2015; Riley et al., 2019; Matiz et al., 2020). For individuals experiencing higher levels of stress, MBSR (Bouw et al., 2019), MBIs (Pizzoli et al., 2020; Schnepper et al., 2020), and TM (Nidich et al., 2016; Sumter et al., 2009) were found to be effective interventions. For individuals suffering from sleep difficulties, MBIs (Zheng et al., 2020) and TM (Abrams & Siegel, 1978; Nidich et al., 2016; Sumter et al., 2009) were found to be effective in improving sleep quality and duration. For individuals suffering from alcohol and substance use disorders, Vipassana meditation was observed to be effective for reducing use (Bowen et al., 2006; Simpson et al., 2007). For individuals suffering from low self-esteem and mood disturbances, MBSR (Bouw et al., 2019; Samuelson et al., 2007), TM (Abrams & Siegel, 1978), and Vipassana (Bowen et al., 2006; Chandiramani et al., 1995; Perelman et al., 2012) were found to be effective in improving symptoms. Individuals suffering from somatoform symptom complaints observed improvements after practicing an MBI (Riley et al., 2019). Improvements for individuals suffering from symptoms related to trauma history were found after practicing TM in particular (Nidich et al., 2016, 2017). Finally, the majority of studies assessing dispositional mindfulness in quarantine and lockdown found associated improvements in anxiety, depression, and psychological distress (Conversano et al., 2020; Dubey et al., 2020; Jiménez et al., 2020; Saricali et al., 2020; Sweeny et al., 2020; Wielgus et al., 2020).

Feasibility and Adherence. Based on the studies reviewed, meditation and MBIs during lockdown and quarantine appear to be feasible practices which are easily implemented, cost-effective, and yield tangible psychological results within a relatively short duration of time. It is important to note that although the length, depth, and format of the interventions vary, adherence was found to be high and each elicited beneficial psychological effects. Matiz et al. (2020) implemented an 8 week MBI among female school teachers at the beginning of the pandemic in Italy. After starting the initially in-person intervention, the Italian government locked-down the region and the remaining MBI was completed remotely through virtual lessons and 30 minute daily at-home practices. The adherence to the intervention was high, with the time spent practicing averaging 26 minutes per day (Matiz et al., 2020). Using a shorter intervention, Pizzoli et al. (2020) likewise observed a high rate of adherence; and observed that 240 of the 294 participants completed the entire study which consisted of a single 7 minute guided audio MBI (Pizzoli et al., 2020). Zheng et al. (2020) implemented a 12 day MBI during lockdown in Wuhan, which consisted of a 10-minute MBI being practiced each morning. Adherence was high here as well, with 55 of the 60 participants in the mindfulness condition completing all of the daily practices (Zheng et al., 2020). Finally, Schnepper et al. (2020) implemented a 14-day compassion-focused MBI using smartphones during lockdown and observed that participants in the intervention group demonstrated high adherence to the guided meditation exercises (e.g., they completed the practices on average 11.5 of the 14 days). Unlike pharmaceutical treatments which have the potential for side effects, as well as therapy which can be time-consuming, costly and unavailable, the practice of meditation and MBIs can be taken up by individuals from the comfort and convenience of their own living space.

With the advent of modern technological advances, there is currently a plethora of meditation and mindfulness applications which can be conveniently downloaded onto an individual’s smart phone; which is particularly useful for individuals isolated in an intensive care unit or quarantined in their home (Flett et al., 2019; Ho et al., 2020; Yanyu et al., 2020). Additionally, individuals who find themselves isolated in an intensive care unit on the brink of death, due to the severity of their Covid-19 symptoms, or prisoners who are on death row, faced with the imminent reality of their own demise, may utilize meditation and mindfulness to help them accept their situation with more openness, in turn, reducing feelings of mortality salience while facing these existential threats (Niemiec et al., 2010).

Generalizability and Diversity. It is important to point out that the prison literature and recent lockdown and quarantine studies reflect the diversity of the populations whom the utility of meditation and MBIs are generalizable to. As previously mentioned, minoritized individuals, people of color, and low income households have been disproportionately affected by the pandemic and prison system and are especially in need of efficacious interventions. Although this is the case, the majority of the participants in the prison studies were Caucasian, which may reflect some form of racial disparity in the ability to access alternative treatments within the prison system. For example, Abrams and Siegel (1978) reported that the participants in their prison study were 24% Black and 16% Mexican-American, while Simpson et al. (2007) reported a sample that was 12.9% Black, 7.3% Native American, and 6.6% Latino. The disparity observed highlights the need for future research into what may be contributing to the demographic differences observed among research participants in prison settings. As the studies in lockdown and quarantine were conducted internationally, the participants in these studies were composed of diverse groups from various countries, cultures, religions, ethnic and socio-economic demographics. The majority of the studies reviewed controlled for covariates which could otherwise act to confound the possible effects of meditation and MBIs. Importantly, while controlling for these variables, beneficial effects were still observed in the majority of the studies. The overall finding of effects among different populations, in different countries and different settings, with different forms of meditation and MBIs being implemented, increase the external validity and generalizability of these findings. Taken together, meditation and MBIs appear to be generalizable interventions for disenfranchised groups and minoritized individuals globally.

Solitude is a closely related construct to isolation which needs to be distinguished for an understanding of their subtle differences and potential effects. Generally, both isolation and solitude pertain to the experience of an individual being alone; however, solitude is often sought out by an individual through their own volition and inner drive (e.g., for purposes of meditation, philosophical contemplation, communion with nature; Rubin et al., 2014; Coplan & Bowker, 2013). Isolation in its own right is usually avoided by individuals and is often forced upon them via an outside source (e.g., forced exclusion from social interaction by authorities during a quarantine or imprisonment). Interestingly, solitude itself has been found to decrease symptoms of stress, induce relaxation, as well as increase positive affect when individuals focus their minds on positive thoughts (Nguyen et al., 2018). It is important to bear in mind that these positive effects of solitude only occur in the presence of an individual who actively focuses and generates positive cognitions, not when an individual negatively ruminates. For example, research has found that even engaging in brief periods of loving-kindness meditation, which focuses on sending positive thoughts to others, increases positive emotions along with feelings of social connection, while simultaneously decreasing feelings of social isolation (Hutcherson et al., 2008). This type of meditation may be especially pertinent for quarantine dwellers who are anxious about seeing others for fear of infection; allowing them to maintain a feeling of social connection, mitigate feelings of loneliness, and transform their feelings of isolation and worry (Polizzi et al., 2020).

As the Covid-19 virus particularly degrades the health of those with a compromised immune system, it is important to note that MBIs have been shown to increase the body’s antibody response after exposure to the influenza vaccine and a stressful situation (Davidson et al., 2003). When individuals are surrounded by an environment inundated by news of the pandemic on a daily basis, fear may rapidly proliferate and lead to an overactive amygdala response. Consequently, this can contribute to the release of increased stress hormones alongside maladaptive cognitions and behaviors, such as fear, anger, depression, and anxiety (Flandreau et al., 2012). FA meditation (e.g., concentrating on the breath, a candle, and visualization), however, has been shown to decrease amygdala reactivity when meditators are exposed to emotional sounds (Brefczynski-Lewis et al., 2007). This ability may be exceedingly helpful when trapped in quarantine or in a hospital. As previously discussed, a recent study conducted in Wuhan, China during the pandemic, found that individuals who were able to practice mindfulness, especially an activity which induced a “flow state” during their time in quarantine, fared better on psychological health measures and overall well-being (Sweeny et al., 2020).

In summary, if practiced by individuals isolated during quarantine, various types of meditation can be utilized to ameliorate negative feelings of loneliness, fear, and worry, improve psychopathological symptoms such as depression and anxiety, bolster physiological functioning, and increase overall well-being, allowing for a potentially positive transformative quarantine experience.

Limitations of the Review and Future Research

This current review is limited insofar as the data on quarantine and lockdown populations utilizing meditation and MBIs is still limited and in its infancy. Furthermore, studies on prisoner populations along with any future studies on quarantine populations will always be partly quasi-experimental in nature; as it would be unethical to randomly assign individuals to actual prison or quarantine settings. The data which can be gleaned, however, will have strong external validity due to the real-world quarantine setting. As previously mentioned, the demographics found within the prison studies were conducted with majority Caucasian individuals and to some extent limits the generalizability of the findings to other groups. Physiological and neurological measures are also difficult to collect in prison and quarantine settings, which limits data to subjective reporting. To counteract this, future studies can try to implement remote computerized cognitive assessments in order to measure relevant psychological and cognitive variables; which is in a manner that is safe to both participants and researchers. Controlling for extraneous confounding variables such as distractions from the meditation or mindfulness practice, incorrect meditation, and interference from authorities, may affect the results found in the prison, lockdown and quarantine studies, and are exceedingly difficult to control and account for. Future studies should try to factor these in as covariables whenever possible. Dosing is another important factor. How long do individuals need to engage in these various practices in order to experience benefits, are there any possibilities of iatrogenic effects? Future studies may wish to seek out answers to these important questions. Lastly, the current state of the literature does not allow us to separate interventions that are religion-based from those that are secular in their implementation. We recognize and, in our descriptions, highlight the conceptual differences among the various practices; however, even religion-based meditations can also be practiced in a secular way. For example, Vipassana meditation which derived from Buddhism (considered a religion by many) is now practiced in many countries in a secular way. Based on our inclusion criteria, we have included all types of MBI in the manuscript that were found to be practiced by individuals in prison, quarantine and lockdown settings. As such, both religious and secular meditation and MBIs are included.

Conclusion

A comparison of the experience of prisoners to the current quarantines and lockdowns being experienced around the world sheds light on their similitudes. Both situations elicit maladaptive psychological, behavioral, and physiological responses; and in particular, they exacerbate pre-existing psychopathological symptoms. However, it is important to emphasize that the situations are not comparable in terms of their intensity, length, or severity. Research studies on incarceration, however, do provide guidance for quarantine and lockdown situations. As we continue to work as a society to overcome the growing pandemic, the utilization of various forms of meditation and MBIs is a cost effective, flexible, and efficacious psychological remedy.

ORCID iD

Mikell Bursky https://orcid.org/0000-0001-5250-2203