Effect of mindfulness-based cognitive therapy on rumination and post-traumatic growth in patients with acute cerebral infarction: A randomized controlled trial

Abstract

Background:

The prevention and management of cerebrovascular diseases, particularly cerebral infarction – the most prevalent type of cerebrovascular disease – pose significant challenges, severely affecting patients’ physical and mental health. Mindfulness-based cognitive therapy (MBCT) has been shown to be effective in treating various mental and chronic conditions. However, there is limited evidence on its effectiveness for treating rumination in patients with acute cerebral infarction (ACI). This study examines the effects of MBCT on rumination, anxiety and depression symptoms, post-traumatic growth, self-care ability, limb motor function, and muscle strength in patients with ACI.

Methods:

In this randomized, single-blind, parallel, single-center controlled trial, participants were recruited from the Department of Neurology and allocated randomly to either 6 weeks of mindfulness cognitive therapy or standard care. The outcomes were assessed at baseline and post-intervention (6 weeks) using the simplified Chinese event-related rumination inventory, the hospital anxiety and depression scale, the simplified Chinese post-traumatic growth inventory, the modified Barthel index (MBI), Brunnstrom hemiplegic motor function assessment, and the Lovett Muscle strength scale.

Results:

Ninety-five subjects were randomly sorted into either the intervention (n = 48) or control group (n = 47). During the study, 5 (5.26%) participants were lost to follow-up, leaving 90 (94.74%) to complete the intervention. Post-intervention, both groups exhibited increased total and purposive rumination scores, with the intervention group scoring higher (P < .05). Intrusive rumination decreased in both groups, with a more significant reduction observed in the intervention group (P < .05). Both groups showed reduced hospital anxiety and depression scores, though the intervention group had lower scores (P < .05). The intervention group also had higher total and subscale scores for post-traumatic growth than the control (P < .05). The MBI scores improved in both groups, with the intervention group showing higher scores (P < .05). However, no significant difference was observed in the improvement of limb motor function or muscle strength between the intervention and conventional care groups (P > .05).

Conclusion:

MBCT can improve the purposeful rumination and self-care ability of patients with ACI, alleviate anxiety and depression symptoms, and foster post-traumatic growth. However, it did not significantly improve limb motor function or muscle strength.

1. Introduction

Stroke is a major chronic noncommunicable disease that seriously endangers human health. According to stroke data published in The Lancet in 2024, stroke is the third leading cause of death worldwide; in 2021, there were 7.3 million stroke-related deaths, accounting for 10.7% of all deaths that year, as well as 11.9 million new stroke events and 93.8 million stroke survivors. Disability-adjusted life years (DALYs) due to stroke have been reported as 160.5 million, accounting for 5.6% of all DALYs.^[1] In China, stroke is the leading cause of death among adults. A 2023 cross-sectional survey published in JAMA Network Open involving 676,394 Chinese adults aged ≥ 40 years reported the existence of a substantial national stroke burden, with approximately 3.4 million (95% CI, 3.3–3.6 million) documented stroke cases and 2.3 million stroke-related deaths annually. Notably, ischemic stroke constituted 86.8% of total cases.^[2] Cerebral infarction is the most common cerebrovascular disease, with a high incidence, high disability rate, high recurrence rate, and high fatality rate. Acute cerebral infarction (ACI) not only leads to physical impairments, but it also triggers a series of psychological problems, including anxiety, depression, and fear. During the first year after a stroke, approximately 1 in 3 individual experience depression and anxiety.^[3]

Patients in a prolonged recovery cycle often repeatedly focus on and reflect on various aspects of their disease, including the disease event itself, its possible causes and consequences, and their emotional state; this cognitive process is known as rumination. Rumination, which can be either intrusive or purposeful, refers to cognitive processing that results in changes in cognition following traumatic events and negative changes. Intrusive rumination denotes maladaptive, repetitive thinking in which individuals passively dwell on the causes, results, and negative emotions associated with distressing events. In contrast, purposeful rumination involves adaptive cognitive processing where individuals actively engage in understanding events, constructing meaning, and solving problems.^[4] Rumination, in its different forms, is an important factor affecting the realization of post-traumatic growth or the occurrence of post-traumatic stress disorder.^[5,6] It is closely related to the occurrence of mental health conditions such as depression and anxiety, and thus can substantially affect patients’ quality of life and recovery.^[7] Therefore, improving the rumination level of patients with ACI is necessary to promote their mental well-being. Studies have shown that mindfulness plays an important role in supporting and regulating both physical and mental health.^[8] Mindfulness refers to an internal state of consciousness that is characterized by focused attention on moment-to-moment experience.^[9] Through mindfulness training, individuals can improve their mindfulness levels and alleviate negative emotions such as anxiety and depression. The core structure of mindfulness is decentralization, also known as re-perception, which allows individuals to shift their perspective from immersion in subjective experience to objective observation of their internal experience, maintaining psychological distance.^[10,11] Mindfulness-based cognitive therapy (MBCT) is a form of psychotherapy that combines cognitive behavioral therapy and mindfulness-based stress reduction, with mindfulness training as its core.^[12] MBCT was developed to prevent the risk of relapse in individuals with a history of recurrent depression. It helps individuals identify and detach from rumination by redirecting their attention to bodily sensation. This present-moment sensory awareness is considered incompatible with the contemplative mode that focuses on distressing symptoms and their possible causes and consequences.^[13] Moreover, by focusing attention on the body, contemplative thought processes can more easily be recognized as what they are – overly negative predictions based on experience rather than objective reality.^[14] Currently, the effectiveness of MBCT has been demonstrated in treating various mental and chronic diseases.^[15–19] However, there is limited evidence regarding the effectiveness of MBCT in addressing rumination in patients with ACI.^[20] Therefore, this study aimed to determine whether MBCT acted as an effective alternative therapy for the psychological well-being of patients with ACI. The primary outcome measure was the level of rumination in patients with ACI. Secondary outcomes included patients’ anxiety and depression symptoms, as well as the level of post-traumatic growth. Additional outcome indicators of interest were self-care ability in daily life, limb motor function, and muscle strength.

2. Methods

2.1. Study design and participants

Recruitment was conducted at the Department of Neurology of the Third People’s Hospital of Yunnan Province from April 2024 to October 2024. Prospective subjects were screened by clinical research physicians for on-site interviews with clinical investigators, after which informed consent was obtained. The participants did not receive any financial compensation for the study.

We designed a randomized, single-blind (evaluator-blind), parallel, single-center, concurrent, 2-arm randomized controlled trial (RCT) to determine the efficacy of MBCT. Participants were randomly assigned to the MBCT intervention or control groups in a 1:1 ratio. The study protocol has been registered in the Chinese Clinical Trials Registry (ChiCTR2400083117), and was approved by the Ethics Committee of the Third People’s Hospital of Yunnan Province (2024KY017).

The inclusion criteria were as follows: imaging changes indicative of cerebral infarction confirmed by head computed tomography (CT) and magnetic resonance imaging, with a diagnosis of ACI; first onset, with onset occurring < 2 weeks; patients aged between 18 and 75 years; basic reading and writing ability, and the ability to use simple smartphones; anxiety or depression score ≥ 8 points on the hospital anxiety and depression scale (HADS)^[21]; and clear awareness, with a Montreal cognitive assessment scale (MoCA) score ≥ 26 points.^[22] The exclusion criteria were as follows: patients with other serious physical conditions, such as epilepsy, myocardial infarction, malignant tumors, or severe infections; patients with an organic mental illness or a history of mental illness; and individuals who received MBCT or other psychological interventions in the past 3 months. The termination/discontinuation criteria were as follows: patients who did not complete the intervention according to the experimental plan and discontinued midway; patients who could not adhere to MBCT training, including those who participated in MBCT training fewer than 4 sessions or failed to complete homework more than twice a week, all of which made it difficult to evaluate the intervention’s effectiveness; and the occurrence of serious complications during the intervention.

2.2. Sample size

In the present study, we aimed to assess the impact of 2 treatments using patient rumination levels as the primary outcome. Prior to the main trial, we conducted an 8-week pilot study with 10 patients with ACI (n = 5 per group), adhering to the inclusion and exclusion criteria. Based on the results of the pilot study, we utilized the PASS software to calculate the required sample size. Employing a 2-sample t-test with a significance level of α = 0.01 and a power of 1 − β = 0.9, we determined that a sample size of 16 participants per group was necessary. Considering a 20% dropout rate, the total sample size was adjusted to a minimum of 40, and the final sample size was 95 subjects (see Table S1, Supplemental Digital Content, https://links.lww.com/MD/P23 for the data and results of the pilot study).

2.3. Randomization and blinding

This study utilized simple randomization in its design. An independent statistician generated the allocation sequence using Excel’s RANDBETWEEN function to randomly assign each participant a number of either “1” (control group) or “2” (intervention group). The randomization scheme and corresponding group assignments were recorded on allocation cards, which were sealed in sequentially numbered opaque envelopes (from 1 to 95), which were prepared prior to enrollment. A research assistant blinded to group assignments distributed these envelopes strictly following the chronological order of participant enrollment. The final allocation yielded 48 participants in the intervention group and 47 in the control group. The study flow is presented in Figure 1 (CONSORT diagram). To maintain single-blinding, data collectors were unaware of group assignments, while intervention administrators were necessarily unblinded to ensure adherence to the treatment control.

Figure 1.

CONSORT 2010 flow diagram.

2.4. Intervention

All participants received standard care, including neuronal nutrition, cerebral blood flow enhancement, blood pressure and glucose management, symptomatic treatment, health education, and general psychological support. The intervention group also underwent MBCT for 6 weeks in combination with standard treatment. Upon study completion, the control group optionally received the same MBCT. Rehabilitation therapists employed 6 questionnaires to assess primary (rumination level) and secondary outcomes (anxiety, depressive symptoms, and post-traumatic growth) at baseline (T0, pre-intervention) and post-intervention (T1, week 6). Additionally, the self-care ability, limb motor function, and muscle strength were evaluated. T0 assessments were conducted face-to-face prior to the first intervention, and the T1 assessment was conducted either face-to-face during the patient’s return visit to the hospital or via telephone follow-up for those who did not return.

2.4.1. MBCT intervention

2.4.1.1. Formation of the intervention team

The study team consisted of the following members: 1 attending physician from the Department of Neurology, responsible for daily medical care; 1 head nurse from the Department of Neurology, responsible for organizing and overseeing nursing activities to ensure their smooth operation; 1 rehabilitation therapist, responsible for rehabilitation treatment and questionnaire collection; 2 psychological counselors (national second-level certification holders with MBCT completion certificates and over 3 years of experience in MBCT), responsible for training group members and assisting in the formulation and implementation of intervention programs; 1 nursing assistant, responsible for patient coordination and communication; and 1 master’s-level nursing student (with a background in mindfulness-based stress reduction), responsible for the design, implementation, and data analysis of the program.

2.4.1.2. Developing the intervention program

The intervention plan implemented in this study was based on The Mindful Way Workbook by Teasdale et al.^[23] A preliminary draft of the intervention protocol was developed through a comprehensive review of the national literature, followed by iterative revisions conducted by a multidisciplinary expert panel. The panel comprised 10 members: 5 nursing professionals (including 4 deputy chief nurses – 3 who were master’s candidates and 1 who was an undergraduate – and 1 professor pursuing a doctoral degree) and 5 physicians (1 associate chief physician with an undergraduate degree and 4 chief physicians, 3 of whom were doctoral candidates and 1 who was an undergraduate). Building on this foundation, the team members systematically discussed and refined the draft protocol. Subsequently, 10 ACI patients meeting the inclusion and exclusion criteria were enrolled in an 8-week pilot study. Post-pilot validation and protocol refinement led to 3 key modifications: each session’s exercise content was streamlined to a single component to enhance simplicity and accessibility; dynamic mindfulness practices (e.g., mindful stretching, movement, and walking) were prioritized in the initial 3 sessions to align with patients’ physical rehabilitation goals; and informed by empirical evidence from prior studies^[20,24,25] and participants’ feedback on their physical/cognitive status, the original 8-week schedule (8 sessions) was restructured into a condensed 6-week format while still retaining the total session count (see Supplementary File S1, Supplemental Digital Content, https://links.lww.com/MD/P23 for the data and results from the expert group discussion and pilot study ). MBCT in this study consisted of 8 modules, with each module addressing a different topic, and the weekly session included 3 parts: a review of the previous session’s practices, theoretical instruction, and mindfulness practice with assigned homework. The detailed intervention program is shown in Table 1.

Table 1.

Mindfulness-based cognitive therapy intervention programs for patients with acute cerebral infarction.

Time/theme	Goal	Content of intervention	Form and location of intervention	Homework
Session 1: Initial exploration of mindfulness	(1) Establish a trusting relationship with the patient. (2) Understand mindfulness and attention to the body.	1. Mutual acquaintance: Assess the basic situation of the patient, understand and comfort the patient, explain the purpose and significance of the study, and gain the trust and support of the patient. Introduce the study members to the patients, and the patients to each other to get to know each other. Give a short explanation of the course schedule, emphasize the need to follow the principles of confidentiality, respect, autonomy, and nonjudgment throughout the course, and complete the first questionnaire. Distribute the Mindfulness-Based Cognitive Exercise Guidebook, Homework Record Sheet, Pleasure and Displeasure Experience Calendar, and Mindfulness-Based Cognitive Exercise Audio, and teach how to use and record them. 2. Knowledge explanation: Introduce mindfulness, mindfulness-based cognitive therapy, the treatment and prognosis of acute cerebral infarction, the relationship between mindfulness and stroke, and the contents of mindfulness stretching and mindfulness of breathing. 3. Exercises: Mindful stretching and mindful breathing: With the audio, guide the patient to perform mindful stretching and mindful breathing. Firstly, perform some gentle physical exercises, if the patient has health problems, he/she only needs to follow the instructions to do imagery exercises, and realize his/her own body’s sensations and emotions during the exercises; secondly, cultivate the moment-by-moment awareness in the breathing. After the exercise, patients are guided to share their feelings, exchange and discuss, summarize and assign homework, and inform the time and content of the next session.	Intervention forms: Face-to face groups Location: Neurology Demonstration Room, Third People’s Hospital of Yunnan Province, China	Mindful stretching and mindful breathing
Session 2: Life in the mind	Transform from connecting to experience through thinking to directly perceiving experience.	1. Review the contents of the exercises in the last session, guide patients to exchange the completion of homework, and share the recording experience. 2. Knowledge explanation: 2 ways of cognition: thinking and direct perception; explain the content of mindful movement. 3. Exercise content: Mindful walking: Walking with each step, without thinking about the destination, maintaining awareness of the body’s movement, and letting go of thoughts and emotional feelings about the body’s perception. (If you have difficulty moving their limbs, they can just follow the audio and do the imagery exercise.) After the exercise, guide the patients to share their feelings about the exercise, exchange and discuss, summarize the exercise and distribute the Pleasure Experience Calendar, explain how to fill in the form and the requirements, assign it as homework, and tell them the time and content of the next session.	Intervention forms: Face-to face groups. Location: Neurology Demonstration Room, Third People’s Hospital of Yunnan Province, China	(1) Mindfulness movement (2) Fill out the Pleasure Experience Calendar
Session 3: Coming back to the present moment	Cultivate moment-to-moment awareness, a nonjudgmental awareness.	1. Review the content of the exercises in the last course, guide patients to exchange the completion of homework and share the recording experience; lead patients to exchange the completion of the pleasure experience calendar, share the pleasure recording experience, and guide patients to use it as an opportunity to notice their thoughts, emotions and body feelings each time a pleasure experience occurs. 2. Knowledge Explanation: “Where is your mind stuck this minute? Is it in this room, fully engaged in the present moment?” Explain to the patient how to detach from those purposeless, meaningless moments of mindfulness. 3. Exercise: Mindfulness Movement: A series of gentle stretches to become aware of one’s own body and weaken the entanglement of thoughts in the mind. The purpose of this exercise is to increase the patient’s direct perception of the body, to become aware of their own body, and to accept it as it is, rather than working out or pushing their stretching limits. After the exercise, patients are guided to share their feelings, exchange and discuss, summarize and distribute the Unpleasant Experiences Calendar, explain how to fill it out and its requirements, assign it as homework, and inform when and what the next session will be.	Intervention forms: Face-to face groups. Location: Neurology Demonstration Room, Third People’s Hospital of Yunnan Province, China	(1) Mindful walking (2) Fill out the Unpleasant Experiences Calendar
Session 4: Identifying avoidance responses	Weaken the habit of trying to avoid or cut off painful feelings.	1. Review the content of the exercise in the last session, guide patients to share the completion of their homework and share the recording experience; lead patients to share the completion of their unpleasant experience calendar and share the unpleasant recording experience, guide patients to accept unpleasant or uncomfortable emotional feelings, and each time an unpleasant experience occurs, take it as an opportunity to be aware of their thoughts, emotions, and physical sensations. 2. Knowledge Explanation: What is avoidance reaction? Anatomy of the avoidance response and how to deal with it. 3. Exercise content: Mindful eating of raisins: With the audio, guide the patient to practice mindful eating of raisins (if the patient’s blood glucose is high, replace it with sugar-free soda crackers), using all the senses to slowly perceive the raisin’s touch, flavor, and sensation in the mouth, and to bring a gentle awareness into it. After the exercise, patients were guided to share their experiences and thoughts about this mindfulness exercise, summarize and assign homework, and inform the time and content of the next session.	Intervention forms: Face-to face groups. Location: Neurology Demonstration Room, Third People’s Hospital of Yunnan Province, China	Eating a meal in a mindful way
Session 5: Embracing the flow of experiences	Allow your experience to be as it is.	1. Review the contents of the exercises in the last session, guide patients to share the completion of their respective homework, and share the recording experience. 2. Knowledge explanation: How to respond to difficulties and pains in life with mindfulness. 3. Exercise content: Body scan: Guide patients to lie down flat, scan different parts of the body in order, and become aware of the body sensations experienced. After the exercise, guide the patient to share the experience and feelings of this mindfulness exercise, summarize and assign homework, and inform the time and content of the next course.	Intervention forms: Online groups via Tencent meeting software. Location: Patient’s own decision, quiet and comfortable environment is sufficient	Body scan
Session 6: Understanding thoughts as mere thoughts	Thoughts are just thoughts themselves, not facts.	1. Review the content of the exercises in the last session, guide patients to share the completion of their homework, and share the recording experience. 2. Knowledge explanation: Explain the thinking patterns related to emotional triggers. 3. Exercise content: Mindfulness meditation: In conjunction with the audio, guide the patient to practice mindfulness meditation by adopting a comfortable sitting posture, being aware of one’s own experience in each moment, and whenever one notices the mind wandering, simply using the breath as an anchor to gently connect with the present moment, focusing on the sensory changes in the lower abdomen as the breath is breathed in. At the end of the practice, the patient is guided to share the experience and feelings of the practice, homework is assigned, and the time and content of the next session are communicated.	Intervention forms: Online groups via Tencent meeting software. Location: Patient’s own decision, quiet and comfortable environment is sufficient.	Mindfulness meditation
Session 7: Transforming kindness into actionable steps	Recognize that the behavior affects the emotions and can be changed by changing the behavior.	1. Review the content of the exercises in the last session, guide patients to share the completion of their respective homework, and share the recording experience. 2. Knowledge presentation: Discuss and share with the patient the activity he/she carries out daily and whether the activity nourishes his/her mood or makes him/her depressed. Guide the patient to recognize that behavior affects mood and that mood can be changed by changing behavior. 3. Exercises: Controlling and pleasurable list filling: Guide the patient to list 10 controlling activities and 10 pleasurable activities, compile these activities into their life when they are in a good mood, and use these activities to respond to a low mood. 3-minute breathing space: With audio, guide patients to practice 3-minute breathing space in conventional and responsive ways: when you perceive a painful or disliked feeling, “inhale” into that part of the body and “exhale” out of it when you exhale, and bring the perception there. Learn to look at thoughts differently and recognize symptoms of a downward spiral early on. After the exercise, guide the patients to share their feelings, exchange and discuss, summarize and assign homework, and inform the time and content of the next session.	Intervention forms: Online groups via Tencent meeting software. Location: Patient’s own decision, quiet and comfortable environment is sufficient.	(1) Apply mindfulness to daily life (2) Three-minute breathing space exercise
Session 8: Envisioning the future	Strengthen mindfulness exercises.	1. Review the content of the exercises in the last session, guide patients to exchange their homework completion, and share the recording experience. 2. Knowledge explanation: The benefits of mindfulness exercises; thinking about the motivation of mindfulness exercises, and considering mindfulness exercises as a part of life. 3. Exercise content: Body scanning: With the audio, guide the patient to conduct a body scanning, and plan a future full of mindfulness. When waking up in the morning, focus on the breath, pay attention to the process of 3 consecutive breaths, and allow the breath to proceed naturally. Upon rising, bring awareness to daily activities such as washing up, eating breakfast, doing chores, and working, so that mindfulness is integrated into daily life. Before going to bed, again focus your attention on your breathing for at least 3 full breath processes. Compassionate meditation exercise: Send compassionate blessings to others and yourself. After the exercise, guide the patients to share their gains and the changes after the positive thinking training, summarize the whole process and take the 2nd questionnaire.	Intervention forms: Online groups via Tencent meeting software. Location: Patient’s own decision, quiet and comfortable environment is sufficient.	Encourage patients to begin a daily mindfulness journey

2.4.1.3. Implementing the intervention program

Before the formal intervention, the researcher conducted assessment interviews with potential participants, with each 1 lasting approximately 30 minutes. The objectives of these interviews were to: evaluate the patient’s baseline condition, explore the sources of emotional distress, and build rapport and trust; introduce the purpose, significance, and background knowledge of MBCT, and analyze how the therapy might benefit the individual; and emphasize the importance of patient’s active participation, explain the daily time required, and clarify the need for full engagement over the 6-week course.

The MBCT intervention program was implemented with the assistance of the lead investigator (who holds a certificate of completion in MBCT) and 2 national-level counselors (both certified in MBCT with over 3 years of relevant experience). Additionally, a member of the nursing team served as the course assistant, responsible for assisting in the implementation of the sessions and managing any unexpected situations. Due to the length of hospital stays, we used both in-hospital face-to-face sessions and remote communication using Tencent Meeting Software. Users could easily join a meeting by entering the 9-digit meeting ID provided by the host. Upon joining, they could enable their camera and microphone to facilitate communication and interaction. Meetings could be accessed from various devices, such as a desktop, laptop, smartphone, or tablet, provided that the Tencent meeting software was installed. This intervention was conducted in small groups of 3 to 6 patients using a combination of these devices to effective implementation. Starting 48 hours after a patient’s condition stabilized (as indicated by stable hemodynamics and vital signs), the intervention was performed 4 times during hospitalization, twice per week, for 1 to 1.5 hours per session. Sessions were scheduled during 1 of 3 time periods: 10:30 to 12:00; 16:00 to 17:30; or 19:30 to 21:00. Whenever possible, group members were assigned to the same time slot to accommodate mutual availability. After discharge, participants continued the intervention once per week for 4 weeks, with each session lasting 1 to 1.5 hours, via Tencent meeting software. The locations for attending these sessions were chosen by the participants themselves, ensuring that they were quiet and comfortable. Each session included 15 to 30 minutes of knowledge explanation, 20 to 30 minutes of individual mindfulness practice, and 15 to 30 minutes of discussion and sharing. This format was followed across 6 weeks, with homework reinforcing each week’s content. Participants were expected to complete the assigned homework 5 days per week, and the average length of the homework per day was 10 to 20 minutes. During hospitalization, homework was completed under the supervision of a researcher.

The first to fourth interventions were conducted face-to-face in the teaching classroom of the Department of Neurology during the patients’ hospitalization. During the first intervention, the WeChat accounts of patients and their family members were added, and WeChat groups were established. Participants who completed baseline questionnaires before beginning the intervention. The “Mindfulness Cognitive Exercise Guide Manual,” the “Homework Record Sheet,” a calendar of pleasant and unpleasant experiences, and audio recordings of mindfulness exercises were distributed and explained to the participants (see Table S2 and Fig. S2, Supplemental Digital Content, https://links.lww.com/MD/P24 for details on the materials distributed to the research participants). The remaining 4 interventions were carried out through Tencent meeting software. To ensure their adherence, the researcher contacted participants via telephone 1 day before each intervention to remind them of the scheduled intervention. For participants who were unable to attend a scheduled session, the researcher arranged a make-up session within 2 days; those who did not attend the make-up session were considered to have missed 1 class. After each online session, the researchers conducted a brief online survey to assess whether participants faced any difficulties during their practice, which would help them complete the training more effectively. The specific content of the online survey included the following questions: Where did you perform the exercise? Were you accompanied by anyone else during the exercise? What was your experience of this session? Did you encounter any difficulties or problems during the practice?

2.4.2. Routine care

Routine care for participants was provided by clinical registered nurses in the Department of Neurology and involved the following: establishing a good nurse-patient relationship upon admission; introducing relevant disease knowledge to patients and sharing success stories of patients with good recovery to increase patients’ understanding of the disease, strengthen their confidence in recovery, and reduce anxiety and depression; establishing a follow-up file before discharge to record detailed information about the patient’s general health and disease-related conditions; registering the patient’s effective contact information and home address; and establishing a WeChat group to regularly inform patients about their diet, exercise, and medication post-stroke to match the frequency and duration of routine care aligns with the MBCT sessions.

2.5. Outcome measures

2.5.1. Primary outcomes

The Chinese version of the event-related rumination inventory (C-ERRI) was used to assess the rumination levels in patients with ACI. This scale, compiled by Cann et al,^[26] is based on the theory of post-traumatic growth and assesses individuals’ cognitive processing of highly stressful events. The C-ERRI includes 2 dimensions: intrusive rumination and purposive rumination, each with 10 items, resulting in a total of 20 items. Individuals were rated on a 4-point Likert scale, based on the frequency of rumination over the last 2 weeks, from “never had this thought” to “often had this thought” after a traumatic event (on a scale of 0–3). The total score ranges from 0 to 60, where the higher the score, the higher the level of rumination. The Cronbach α coefficients of the 2 dimensions are 0.94 and 0.88, respectively.

2.5.2. Secondary outcomes

• (1) The Chinese post-traumatic growth inventory (C-PTGI) was used to assess the level of post-traumatic growth in patients with ACI. Proposed by Tedeschi and Calhoun^[27] in 1995, this inventory assesses positive psychological changes perceived by the individual after traumatic events. The C-PTGI scale has 20 items across 5 dimensions (personal strength, relationship with others, life perception, new possibilities, and self-transformation) and uses the Likert 6-level scoring method, where the frequency of certain experiences after trauma ranges from “none” to “very much.” The total score ranges from 0 to 100, with higher scores predicting higher levels of post-traumatic growth. A median score of 3 is typically considered to represent a moderate level of post-traumatic growth. The Cronbach α coefficient of the C-PTGI scale is 0.90.

• (2) The HADS was used to assess the symptoms of anxiety and depression in patients with ACI. Developed by Zigmond AS and Snaith RP^[21] in 1983, this scale is designed for screening anxiety and depression in-hospital patients. The scale includes 2 subscales related to anxiety (HADS-A) and depression (HADS-D), each of which contains 7 items. A 4-point Likert score was used for scoring, with the total score ranging from 0 to 42, where the higher the score, the more severe the symptoms of anxiety or depression. The Cronbach α coefficients of HADS, HADS-A, and HADS-D were 0.879, 0.806, and 0.806, respectively.

• (3) The modified Barthel index (MBI) was used to assess the ability of patients with ACI to perform activities of daily living. Originally developed by American physiatrist Barthel in 1955, the Barthel index scoring scale^[28] was designed to measure the capacity of individuals with physical disabilities to perform daily self-care activities. The MBI version provides a more detailed and precise scoring system, assigning each item a score of 0, 5, 10, or 15 based on the level of assistance needed. The total score ranges from 0 to 100, with a higher score indicating greater independence in daily life. The Barthel score scale group Kappa values of inter- and intragroup reliability ranged from 0.89 to 0.99.

• (4) The Brunnstrom motor function evaluation was performed to evaluate the limb motor function of patients with ACI. The evaluation divided motor recovery into 3 body regions – upper limb, lower limb, and hand – and 6 stages (relaxation, spasm, co-movement, partial-dissociative movement, dissociative movement, and normal). The Brunnstrom Motor Function Evaluation is a widely utilized tool for assessing motor function recovery in stroke patients.^[29]

• (5) The Lovett muscle strength classification was used to classify the muscle strength of the upper and lower limbs of patients with ACI. The grading of this classification system is as follows: Grade 0, no measurable muscle contraction; Grade 1, slight contraction but no joint movement; Grade 2, full range of joint movement under reduced weight; Grade 3, full range of joint movement against gravity, but unable to resist resistance; Grade 4, movement against gravity and some resistance; and Grade 5, movement against gravity and full resistance.

2.6. Ethical considerations

The study design and procedures conformed with the Declaration of Helsinki. The study was approved by the Ethics Review Committee of the Third People’s Hospital of Yunnan Province (2024-KY017). Participation in this study was voluntary, and participants were free to withdraw from the study at any time. All participants provided informed consent before participation. Patients in the control group were offered the MBCT intervention on a voluntary basis at the study’s conclusion.

2.7. Statistical analysis

Statistical analyses were performed using IBM SPSS 26.0 (Chicago) with a significance level of α = 0.05 for 2-tailed tests. A P-value <.05 indicated statistical significance. Baseline demographics, including sex, age, and education were summarized using frequencies and proportions, with group comparisons conducted using the χ² test and Fisher exact test. Data normality was assessed using the Shapiro–Wilk test and Q–Q plots. For normally distributed continuous variables – including total rumination scores, post-traumatic growth total scores, and subscale scores for life appreciation, new possibilities, relationships, self-transformation, anxiety, and depression – data are reported as the mean ± SD and compared using independent-samples t-tests (between groups) and paired-samples t-tests (within groups). Non-normally distributed variables – such as the personal strength dimension of post-traumatic growth, self-care ability scores, Lovett muscle strength classifications, and Brunnstrom Motor Function scores – are reported as the median (M), 25th percentile (P25), and 75th percentile (P75) and analyzed using the Mann–Whitney U test (between groups) and Wilcoxon signed-rank test (within groups).

3. Results

A total of 95 patients were randomly divided into either the intervention group (n = 48) or the control group (n = 47). During the implementation period, 2 participants in the intervention group chose to withdraw, 1 participant experienced health deterioration, and 2 participants in the control group were unreachable. Ultimately, 90 participants completed the 6-week intervention (intervention group, n = 45; control group, n = 45). No adverse events were reported during the study. There were no statistically significant differences between the 2 groups in terms of baseline characteristics, such as sex, age, household income, and comorbidities (P > .05), as shown in Table 2.

Table 2.

Demographic characteristics of the participants (n = 90).

Variable	Intervention group (n = 45) n (%)	Control group (n = 45) n (%)	χ 2	P
Sex
Male	27 (60.0)	29 (64.4)	0.189	.664
Female	18 (40.0)	16 (35.6)
Age (yr)
<45	6 (13.3)	6 (13.3)	0.212	.899
45 to 60	17 (37.8)	15 (33.3)
61 to 75	22 (48.9)	24 (53.3)
Education
Primary school and below	9 (20.0)	9 (20.0)	0.239	.971
Junior high school	20 (44.4)	22 (48.9)
High school/Technical secondary school	10 (22.2)	9 (20.0)
Junior college and above	6 (13.3)	5 (11.1)
Marital status
Unmarried	3 (6.7)	2 (4.4)	–	.940
Married	35 (77.8)	37 (82.2)
Divorced	4 (8.9)	3 (6.7)
Bereaved spouse	3 (6.7)	3 (6.7)
Occupation
Employed	20 (44.4)	18 (40.0)	0.416	.812
Retired	19 (42.2)	22 (48.9)
Unemployed	6 (13.3)	5 (11.1)
Place of residence
Village	13 (28.9)	14 (31.1)	0.053	.818
City/town	32 (71.1)	31 (68.9)
Living condition
Live alone	2 (4.4)	3 (6.7)	–	1.00
Live with family	43 (95.6)	42 (93.3)
Religious belief
Yes	1 (2.2)	0 (0.0)	–	1.00
No	44 (97.8)	45 (100.0)
Medical expense
Provincial medical insurance	5 (11.1)	6 (13.3)	1.477	.831
Municipal medical insurance	23 (51.1)	20 (44.4)
Urban medical insurance	6 (13.3)	9 (20.0)
New rural cooperative medical system	6 (13.3)	7 (15.6)
Self-funded	5 (11.1)	3 (6.7)
Family monthly Income (CNY)
≤2000	5 (11.1)	6 (13.3)	0.572	.903
2000 to 5000	17 (37.8)	16 (35.6)
5000 to 10,000	16 (35.6)	18 (40.0)
≥10,000	7 (15.6)	5 (11.1)
Hemianopsia
No	42 (97.8)	44 (95.6)	–	1.00
Yes	3 (2.2)	1 (4.4)
Limb mobility disorder
No	4 (8.9)	3 (6.7)	–	1.00
Yes	41 (91.1)	42 (93.3)
Dysphagia
No	40 (88.9)	38 (84.4)	0.385	.535
Yes	5 (11.1)	7 (15.6)
Number of chronic diseases
0	11 (24.4)	11 (24.4)	0.108	.947
1 to 3	28 (62.2)	29 (64.4)
>3	6 (13.3)	5 (11.1)

χ² = Pearson chi-square test; “–”: Fisher exact probability method is used because the theoretical frequency is <5.

3.1. Rumination

The difference in C-ERRI scores between the 2 groups before the intervention was not statistically significant (P > .05). After 6 weeks of intervention, the total and deliberate rumination scores were significantly higher, and the intrusive rumination score was significantly lower in both groups (P < .05). Compared to the control group, the intervention group had higher total and deliberate rumination scores and lower intrusive rumination scores (P < .05), as shown in Table 3.

Table 3.

Mean ± standard deviation of C-ERRI scores in the intervention and control groups at pre-intervention and 6 wk post-intervention.

	Group	Samples	Before intervention	After intervention	t	P
Intrusive rumination	Intervention group	45	14.53 ± 2.12	8.16 ± 2.35	21.36	<.001
	Control group	45	15.04 ± 2.11	14.42 ± 2.04	1.80	.079
	t		−1.15	−13.50
	P		.25	<.001
Purposeful rumination	Intervention group	45	10.78 ± 2.32	24.60 ± 2.16	−43.21	<.001
	Control group	45	11.00 ± 2.48	13.02 ± 2.46	−6.08	<.001
	T		−0.44	23.72
	P		.66	<.001
Total rumination score	Intervention group	45	25.31 ± 2.24	32.76 ± 3.01	−16.22	<.001
	Control group	45	26.04 ± 2.42	27.44 ± 2.32	−3.02	.004
	t		−1.50	9.38
	P		.14	<.001

C-ERRI = Chinese Version of the Event-Related Rumination Inventory

3.2. Anxiety and depression state

There were no statistically significant differences in HADS-A and HADS-D scores between the intervention and control groups before the intervention (P > .05). After 6 weeks of intervention, both groups exhibited significantly reduced HADS-A and HADS-S scores compared to their respective baseline values. Moreover, the intervention group had lower scores than the control group (P < .05) post-intervention, indicating a greater reduction in anxiety and depression symptoms. Detailed results are shown in Table 4.

Table 4.

Mean ± standard deviation of hospital anxiety and depression scale scores in the intervention and control groups at pre-intervention and 6 wk post-intervention.

	Group	Samples	Before intervention	After intervention	t	P
HADS-A	Intervention group	45	12.24 ± 2.34	3.91 ± 1.41	26.47	<.001
	Control group	45	12.67 ± 2.64	9.64 ± 2.24	11.09	<.001
	T		−0.80	−14.54
	P		.42	<.001
HADS-D	Intervention group	45	12.36 ± 1.40	4.00 ± 1.37	31.39	<.001
	Control group	45	12.62 ± 1.37	9.67 ± 1.68	9.59	<.001
	T		−0.70	−18.97
	P		.49	<.001

HADS-A: anxiety, HADS-D: depression.

HADS = hospital anxiety and depression scale.

3.3. Post-traumatic growth

Before the intervention, there was no statistically significant difference in C-PTGI scores between the 2 groups (P > .05). After 6 weeks of intervention, the total post-traumatic growth score, as well as subdomains of life appreciation, personal strength, new possibilities, relationship with others, and self-transformation scores were significantly higher in both groups (P < .05). Compared to the control group, the intervention group had higher scores in all these domains (P < .05). Detailed results are shown in Table 5.

Table 5.

Mean ± standard deviation of C-PTGI scores in the intervention and control groups at pre-intervention and 6 wk post-intervention.

	Group	Samples	Before intervention	After intervention	t/z	P
Life perception	Intervention group	45	11.20 ± 1.74	18.98 ± 2.89	−16.04	<.001
	Control group	45	10.56 ± 1.88	11.22 ± 1.80	−1.75	.086
	T		1.69	15.12
	P		.095	<.001
Individual power	Intervention group	45	9.00 (8.50–10.00)	11.00 (10.00–12.00)	−5.252	<.001
	Control group	45	9.00 (8.50–10.00)	10.00 (9.00–11.00)	−5.06	<.001
	z		−0.35	4.17
	P		.73	<.001
New possibilities	Intervention group	45	8.04 ± 1.43	11.62 ± 1.97	−16.90	<.001
	Control group	45	7.98 ± 1.39	11.33 ± 3.33	−1.59	0.12
	t		0.22	2.24
	P		.82	.028
Relationships with others	Intervention group	45	8.31 ± 1.44	11.09 ± 1.33	−13.668	<.001
	Control group	45	8.09 ± 1.53	8.98 ± 1.56	−3.23	.002
	t		0.71	6.91
	P		.48	<.001
Self-transformation	Intervention group	45	6.86 ± 1.52	11.27 ± 1.67	−13.82	<.001
	Control group	45	7.22 ± 1.35	8.29 ± 1.49	−4.51	<.001
	t		−1.18	8.93
	P		.24	<.001
Total points	Intervention group	45	43.82 ± 3.23	66.04 ± 5.23	−25.636	<.001
	Control group	45	43.07 ± 3.56	47.24 ± 3.45	−6.513	<.001
	t		1.06	19.59
	P		.294	<.001

C-PTGI = Chinese post-traumatic growth inventory.

3.4. Self-care ability

Before the intervention, the difference in the Barthel Index scores of self-care ability of patients between the 2 groups was not statistically significant (P > .05). After 6 weeks of intervention, the Barthel Index scores of both groups increased significantly, and the scores of the intervention group were higher than those of the control group (P < .05), as shown in Table 6.

Table 6.

Mean ± standard deviation of MBI scale scores in the intervention and control groups at pre-intervention and 6 wk post-intervention.

Group	Samples	Before intervention	After intervention	z	P
Intervention group	45	71.00 (65.00–78.00)	90.00 (88.00–93.50)	−5.844	<.001
Control group	45	75.00 (66.50–78.00)	88.00 (80.00–90.00)	−5.849	<.001
z		−0.563	−4.13
P		.57	<.001

MBI = modified Barthel index.

3.5. Brunnstrom motor function evaluation

Before the intervention, there was no significant difference in limb motor function scores between the 2 groups (P > .05). After 6 weeks of intervention, the limb motor function scores of both groups increased significantly. Although the scores of the intervention group were higher than those of the control group, no statistically significant difference was observed between the 2 groups (P > .05), as shown in Table 7.

Table 7.

Mean ± standard deviation of Bunnstrom motor function evaluation in the intervention and control groups at pre-intervention and 6 wk post-intervention.

	Group	Samples	Before intervention	After intervention	z	P
Upper limb	Intervention group	45	4.00 (3.00–4.00)	6.00 (5.00–6.00)	−6.049	<.001
	Control group	45	4.00 (3.00–4.00)	6.00 (5.00–6.00)	−5.837	<.001
	z		−0.268	−0.955
	P		.789	.340
Finger	Intervention group	45	4.00 (3.00–4.00)	5.00 (5.00–5.00)	−5.722	<.001
	Control group	45	4.00 (3.00–4.00)	5.00 (4.50–5.00)	−5.765	<.001
	z		−0.402	−0.880
	P		.687	.379
Lower limb	Intervention group	45	4.00 (3–4)	5.00 (6.00–5.00)	−5.898	<.001
	Control group	45	4.00 (3.00–4.00)	5.00 (6.00–5.00)	−5.895	<.001
	Z		−0.12	−0.771
	P		.904	.441

3.6. Lovett muscle strength classification

Before the intervention, there was no statistically significant difference in muscle strength scores between the 2 groups (P > .05). After 6 weeks of intervention, the muscle strength scores of both groups increased significantly. Although the scores of the intervention group were higher than those of the control group, no statistically significant difference was observed between the 2 groups (P > .05), as shown in Table 8.

Table 8.

Mean ± standard deviation of Muscle Strength Classification scores at pre-intervention and 6 wk post-intervention.

	Group	Samples	Before intervention	After intervention	z	P
Upper limb	Intervention group	45	4.00 (3.00–4.00)	5.00 (5.00–5.00)	−5.788	<.001
	Control group	45	4.00 (3.00–4.00)	5.00 (4.00–5.00)	−5.557	<.001
	Z		−0.393	−1.513
	P		.694	.13
Lower limb	Intervention group	45	4.00 (3.00–4.00)	5.00 (4.00–5.00)	−5.606	<.001
	Control group	45	4.00 (3.00–4.00)	5.00 (4.00–5.00)	−4.796	<.001
	z		−0.455	−1.738
	P		.649	.082

4. Discussion

4.1. Mindfulness-based cognitive therapy improves rumination levels in patients with ACI

In this RCT, we evaluated the efficacy of MBCT in 90 patients with ACI. MBCT, which combines mindfulness-based stress reduction therapy with principles of cognitive behavioral therapy, emphasizes both meditative practices and psychoeducation. This intervention is currently one of the most widely used treatments for reducing rumination in clinical patients.^[30] Rumination has characteristics of a “learned behavior,” meaning its frequency, intensity, and nature can be changed through effective interventions. Within its 2-dimensional structure, intrusive rumination presents a maladaptive form of cognitive processing that impedes psychological adjustment, leading individuals to passively focus on the causes, consequences, and emotional distress associated with negative events, thereby contributing to and prolonging symptoms of depression and other psychological conditions. This occurs by reinforcing negative thought patterns, diminishing perceived social support, and impairing problem-solving abilities.^[31] In this study, we found that MBCT reduced intrusive rumination levels in patients with ACI, a finding consistent with previous research by Compen et al^[32] and Jelle et al.^[33] This decrease may be attributed to improved self-awareness in participants following the intervention. Improved self-awareness enables patients to recognize and observe their internal experiences, thereby reducing repetitive negative thinking and aiding in participants developing clearer perceptions of their thoughts and emotions. This shift reduces the interference of negative information and events and facilitates recovery from persistent intrusive rumination.^[34] In contrast, purposive rumination is an adaptive cognitive process that promotes psychological adjustment, helping patients to reflect constructively on stressful events, derive meaning from their experiences, and engage in problem-solving, thereby promoting positive behavioral changes and acquiring health-related knowledge.^[4] In this study, levels of purposive rumination – and overall rumination – were significantly improved in patients who received MBCT, which may be related to the improvement in patients’ self-awareness and their cultivation of a nonjudgmental attitude. Patients were encouraged to attend to and accept distressing emotions with openness and compassion, which may have resulted in changes in emotion-related neural activity. By supporting adaptive emotional regulation strategies such as acceptance over avoidance, MBCT helped patients shift away from dysfunctional cognitive patterns, ultimately fostering more effective psychological adjustment and adaptive cognitive processing.^[35]

4.2. Mindfulness-based cognitive therapy can relieve anxiety and depression symptoms in patients with ACI

Our results showed that MBCT alleviated anxiety and depression symptoms in patients with ACI, which aligned with the findings of Mak et al.^[20] Anxiety, depression, and other negative emotions are common in patients with ACI. These negative emotions are closely related to sleep disorders, decline in the quality of life, and hindered recovery process.^[36] In this study, we found that MBCT reduced anxiety and depression symptoms in patients with ACI, which could be attributed to the fact that MBCT helped patients realize their negative cognition and behavior, reflect on and clarify existing thoughts, and explore cognitive responses that aligned with their inner needs through tolerance and acceptance, ultimately improving their anxiety and depression symptoms.^[15]

4.3. Mindfulness-based cognitive therapy can improve post-traumatic growth in patients with ACI

Our results showed that MBCT improved the level of post-traumatic growth in patients, which aligned with the results of a previous study conducted by Stafford et al, showing that MBCT improved post-traumatic growth in women with breast cancer and gynecologic cancer.^[37] The purposeful and constructive contemplation of traumatic events is essential for the cognitive processing that underlies post-traumatic growth.^[5] Post-traumatic growth is the positive psychological changes experienced by individuals who struggle with traumatic negative life events and situations. In patients with ACI, the stress response triggered by the disease often hinders their ability to accurately recognize and process the traumatic event. In this study, we found that MBCT improved the total post-traumatic growth scores in patients with ACI, including scores across all 5 dimensions: personal strength, relationship with others, life appreciation, new possibilities, and self-transformation. These improvements may be attributed to the capacity of MBCT to help patients consciously focus on the present moment while simultaneously reducing fixation on past events and future worries, guiding individuals to identify with themselves in a nonjudgmental and objective manner. Such an approach can enhance patients’ ability to manage emotional fluctuations occurring after trauma, strengthen their emotional self-regulation, and create the psychological foundation necessary for positive transformation. This, in turn, can foster psychological and emotional growth in patients with ACI as they process and recover from their traumatic experiences.^[35]

4.4. Mindfulness-based cognitive therapy can improve the daily self-care ability of patients with ACI

Our results showed that MBCT improved the self-care ability of patients with ACI in daily life, which aligned with the results of Myers et al’s study on promoting perioperative nurses’ self-care ability by cultivating mindfulness.^[38] This may be related to the fact that MBCT alleviates patients’ negative emotions, keeps the body in a relatively stable state, reduces systematic inflammation, and mitigates disease deterioration caused by cascade reactions. Consequently, patients may gain increased confidence in their recovery, demonstrate greater willingness to adhere to treatment plans, and actively engage in communication with medical staff. We posit that mindfulness training may help patients with ACI to develop a clearer understanding of their condition and the associated functional impairments. By encouraging an open and inclusive mind, MBCT may promote better psychological adaption, enhance treatment compliance, and ultimately improve patients’ self-care abilities.^[35]

4.5. Mindfulness-based cognitive therapy did not significantly improve motor function and muscle strength among patients with ACI

Compared to conventional treatment, MBCT did not lead to significant improvements in motor function or muscle strength in patients with ACI. One possible explanation for this is that the physical activity involved in MBCT was not of sufficient intensity to improve limb mobility or muscular strength in this patient population. Additionally, the limited duration of the intervention may have contributed to the lack of significant effects. Traditional MBCT protocols typically involve 2.5 hours of group sessions per week over 8 weeks, supplemented by 45 minutes of individual practice.^[39] In this study, although we increased the frequency of interventions during hospitalization (twice per week), the total intervention was condensed into eight 1-to-1.5-h group sessions over 6 consecutive weeks to accommodate the clinical realities of stroke survivors, particularly the average hospital length of stay in our department. A previously published systematic review showed that a modified mindfulness intervention of 6 weeks or longer could yield positive outcomes for stroke survivors, whereas shorter or less intensive interventions tended to be less effective.^[20]

5. Study limitations

This study has several potential limitations. First, a notable limitation lies in the use of a combined delivery format involving both offline face-to-face sessions and online components. This approach was adopted to ensure adequate intervention dosage and fidelity due to the constraints of the hospitalization cycle for patients with ACI. Although this mixed approach may have introduced some bias, the increased frequency of offline sessions may have enhanced peer support, and some participants reported that obtaining help was more convenient in the online setting. Nevertheless, while the findings demonstrate the feasibility of an online intervention, further research is needed to determine its effectiveness. Second, all outcome variables were subjectively reported by participants via questionnaires, which could have led to recall bias and limited objectivity. Third, we only conducted follow-up after 6 weeks and no longer, which could limit the interpretation of long-term effects and the overall scope of the results. Fourth, the study excluded stroke patients with cognitive impairment and aphasia because of their limited ability to understand instructions or communicate effectively. Therefore, the findings of this study cannot be generalized to this subset of patients, and future studies should explore adapted interventions to address their specific needs. Fifth, although the sample size (n = 95) was statistically justified, the heterogeneity among ACI patients (including variations in disease severity, individual psychological differences, and recovery stages), could not have been fully represented. Future research should incorporate longitudinal follow-ups at 3- and 6-month intervals to better assess the durability of intervention effects, while also integrating biomarkers and neuroimaging techniques to enable multidimensional efficacy evaluation. Additionally, multicenter studies with expanded sample sizes are required to enhance generalizability and validate these findings across diverse clinical populations.

6. Conclusion

Our findings demonstrate that MBCT improves the mental health, emotional well-being, and self-care abilities of patients with ACI. MBCT appears to be an effective method of psychological intervention for enhancing patients’ with ACI. However, we did not find significant improvements in limb motor function and muscle strength in patients who underwent MBCT compared to the control group. Given its high completion rate, MBCT-based interventions can be effectively implemented in neurology departments. In addition, patient families and nurses should consider receiving MBCT-related training and incorporating these practices into routine care.

Acknowledgments

We thank LetPub (www.letpub.com.cn) for its linguistic assistance during the preparation of this manuscript. We extend our heartfelt thanks to Professor Li-Zhu Jiang and Associate Professor Wei-Fen Qiu for their guidance and support in MBCT, and to Dr Qin Liu for providing direction in the statistical analysis. We also acknowledge all the participants for their valuable contributions.

Author contributions

Conceptualization: Zuoju Zhang.

Data curation: Zuoju Zhang.

Formal analysis: Zuoju Zhang, Yuxin Sun.

Funding acquisition: Zuoju Zhang.

Investigation: Yanhong Dong, Yuxin Sun.

Methodology: Zuoju Zhang.

Project administration: Zuoju Zhang, Yanhong Dong.

Resources: Zuoju Zhang, Yanhong Dong, Yuxin Sun.

Software: Zuoju Zhang.

Supervision: Yanhong Dong.

Validation: Zuoju Zhang.

Visualization: Zuoju Zhang, Yuxin Sun.

Writing – original draft: Zuoju Zhang.

Writing – review & editing: Zuoju Zhang, Yanhong Dong.