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training intervention compared with the control group
(78% completed intervention). However, there were
no significant differences in the cognitive functions
executive function, working memory, perceptual speed
or reasoning ability and no significant differences on
self-rated symptoms of burnout, depression and anxiety
(40). This finding in patients with SED is opposite
to the general positive effect of physical activity on
reducing depressive symptoms and anxiety that has
been documented in several meta-analyses (41–43).
In a study by Lindegard et al. (44), patients with SED
were recommended physical activity as a complement
to MMR. Both compliers and non-compliers improved
regarding burnout, depression and anxiety, but there
was no difference between the groups until at the 18
months’ follow-up when compliers reported signi-
ficantly lower levels of depression and burnout. No
significant differences were found between the groups
concerning anxiety (44).
In summary, several meta-analyses demonstrate that
physical activity generally reduces depressive symp-
toms and anxiety. CBT seems to reduce symptoms until
the end of the rehabilitation, but regular aerobic training
may be important to reduce symptoms in the long-term.
Aerobic training at a moderate-vigorous intensity may
be important to facilitate cognitive function.
Mindfulness and meditation. Mindfulness is a medita-
tion technique based on being aware of what is happe-
ning right now, without valuing or judging (45). It is a
popular technique when trying to achieve stress relief.
Mindfulness seems to be positively associated
with psychological health, subjective well-being and
reduced psychological symptoms (46). According to
a review by Creswell (47) mindfulness interventions
improve attention-related cognitive outcomes, such as
sustained attention and working memory performance,
among healthy young adults. Combining mindfulness
meditation, body awareness and yoga seems to faci-
litate relaxation of the body and calming of the mind,
and thereby reduce stress and anxiety (48).
A systematic review and meta-analysis from 2014
evaluated the effects of meditation in RCTs. The
participants were patients with a clinical psychiatric
or physical condition, but also stressed populations
without a medical or psychiatric diagnosis. The review
concluded that mindfulness meditation programmes
have a moderate evidence of decreased anxiety and
depression and low evidence of decreased stress and
increased mental health-quality of life. Compared
with other treatments, such as drugs, physical exercise
and behavioural therapies, there was no evidence that
mindfulness meditation programmes were better (49).
An RCT from 2013 evaluated the efficacy of a
multidisciplinary intervention in patients on full- or
www.medicaljournals.se/jrm
part-time sick leave because of significant symptoms
of work-related stress for months. The intervention in-
cluded workplace-focused psychotherapy, a workplace
dialogue if the patient agreed and a mindfulness-based
stress-reduction (MBSR) course (2 h a week over 8
weeks). The intervention group (n = 69) was compared
with 2 control groups, TAU including individual ses-
sions with a psychologist (n = 71) and a waitlist control
group (n = 58). Significantly more patients in the inter-
vention group (67%) returned to work compared with
patients in the control groups (36% and 26%) after the
treatment. Both the intervention group and the controls
that received TAU reduced their symptoms signifi-
cantly compared with the waitlist control group (50).
In summary, mindfulness interventions can improve
attention-related cognitive outcomes among healthy
young adults, and reduce symptoms of anxiety, depres-
sion and stress in a diverse population. According to
one RCT mindfulness in combination with workplace
interventions could improve RTW in patients with
work-related stress compared with TAU. However,
the effect of mindfulness alone on RTW is unknown.
Yoga. There are many different schools of yoga, but the
key elements for all of them are meditation, breathing
exercises and postures. A systematic review summari-
zed 17 articles of mindfulness stress- reduction, yoga
combined with mindfulness meditation, from 2009
until 2014 in healthy people, and found that most of the
articles showed positive changes in outcomes related
to anxiety and/or stress (51).
However, yoga is not only practiced in wellness
care, but is also used as therapy in healthcare (52).
We found one RCT with an intervention of yoga in
patients with stress-related symptoms. Patients in pri-
mary healthcare (n = 37) with stress-related diagnosis
and self-reported symptoms of stress were treated with
standard treatment comprised of individual physical
activity, pharmacological treatment, if needed, and
individual consultation with a psychologist, phy-
siotherapist, nurse or a counsellor. The patients were
randomized to yoga twice a week during 12 weeks, or
no yoga. Stress was measured by the Perceived Stress
Scale (PSS) and symptoms of anxiety and depression
by Hospital Anxiety and Depression Scale (HADS),
before and after 12 weeks. The results showed a sig-
nificant decrease in levels of stress and anxiety (53).
The level of depressive symptoms did not decrease.
In summary, the only RCT found on yoga was an
intervention for patients with stress-related symptoms,
and it showed a significant decrease in levels of stress
and anxiety.
Qigong. Qigong is a mind-body exercise that can be
practiced at any time and in any place, which may
improve physical health and decrease anxiety and per-