The Effect of Self-Compassion on Psychosocial and Clinical Outcomes in Patients With Medical Conditions: A Systematic Review

Studies about the role of self-compassion have focused primarily on psychological well-being, but there is solid evidence to suggest that self-compassion may have larger and more prominent implications in the medical world. Therefore, this systemic review aimed to investigate the effects of self-compassion on psychosocial and clinical outcomes in medically ill patients. A comprehensive search of several databases from their inception to August 10, 2020, was conducted, which included Ovid MEDLINE(R) and Epub Ahead of Print, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Eligible studies needed to include psychosocial or clinical outcomes of self-compassion in medically ill patients. Nineteen articles (n=2,713 patients; 73.3% females) met our eligibility criteria and were included in this systematic review. There was a negative correlation between self-compassion and psychosocial outcomes such as anxiety, depression, and stress. Moreover, based on self-compassion intervention, there was an improvement in clinical outcomes related to diabetes such as hemoglobin A1c (HbA1c) and blood glucose levels. This systematic review highlights the effect of self-compassion on psychosocial and clinical outcomes. Further studies are needed to evaluate long-term outcomes of a self-compassion-based-intervention to highlight its importance in the role of disease management.

To date, most of the research has directed its efforts toward the role of self-compassion in psychological well-being; however, there is evidence to suggest that self-compassion may well have a stronger contribution to make in the medical world as well. Although the research is limited to the role of selfcompassion for health-related outcomes in medically ill patients, there are promising results to support the incorporation of self-compassion interventions to improve disease trajectory and management. This systematic review aimed to investigate the effects of self-compassion on psychosocial and clinical outcomes in medically ill patients.

Data Sources and Search Strategies
A comprehensive search of several databases from their inception to August 10, 2020, was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [13]. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search strategy was designed and conducted by an experienced librarian. Controlled vocabulary supplemented with keywords was used to search for studies describing self-compassion and medical treatment. The actual strategy listing all search terms used and how they are combined is available in the Appendix section ( Table 4).

Eligibility Criteria and Quality Assessment
Studies were deemed eligible if they met all of the following inclusion criteria: 1) investigate selfcompassion; 2) involve patients aged more than 18 years with medical disorders, and 3) deal with psychosocial or clinical outcomes of self-compassion in medically ill patients. Case reports, conference abstracts and/or abstracts, and articles that were not in English were excluded from the study. The quality of each study was independently evaluated by two authors using the National Institutes of Health (NIH) Quality Assessment Tool [14]. Results of the quality assessment of all included studies are shown in the Appendix section ( Table 5). All observational and cross-sectional studies were judged to be of good quality. The patients appeared to represent the whole experience of the investigator and the exposure and outcomes were adequately ascertained, and the length of follow-up was also deemed adequate.

Study Selection and Characteristics
A total of 5,024 records were identified from the initial search of electronic databases. After the exclusion of duplicated articles, 2,827 articles underwent title and abstract review. Following the exclusion of articles that did not fulfill the eligibility criteria, 27 articles underwent a full-length review. Eight articles were further excluded, for reasons shown in the Appendix section ( Figure 1). Finally, 19 articles (n=2,713 patients, of which 73.3% were females) met our eligibility criteria and were included in this systematic review [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. The baseline characteristics of the included studies are comprehensively described in Table 1

Baseline Characteristics
As shown in Table 1, 19 studies were included of which four studies were from the UK, five studies from the USA, four studies from Australia, two studies from New Zealand, three studies from Iran, and one study from China; 2,713 patients were included of which 1,989 were female, with an age range of 26-64 years. Common medical conditions included were diabetes (n=5), breast cancer (n=3), multiple sclerosis (n=1), spina bifida (n=1), celiac disease (n=1), HIV (n=1), brain injury (n=1), migraine (n=1), musculoskeletal pain (n=1), and vulvodynia (n=1). Studies were mostly cross-sectional (n=14), followed by randomized controlled trials (n=2), mixed methods (n=1), longitudinal study (n=1), and quasi-experimental (n=1). Time from diagnosis ranged between 6-18 years for different medical conditions. Treatment options were included for breast cancer and diabetes. Breast cancer treatment options in different studies were similar and included chemotherapy, radiation, surgery, and hormone therapy. Treatment for diabetes included insulin pumps, insulin injections, and lifestyle modifications (diet and exercise).

Psychosocial Outcomes
Eighteen included studies exhibited outcomes of self-compassion using the Self-Compassion Scale (SCS) questionnaire as shown in Table 2. Five studies provided the values of self-compassion based on the average of all subscales from 1-5. The range for the self-compassion values was between 2.8-3.46. Three studies looked at specific subscales with the SCS [16,18,30]. A study by Ambridge, Fleming, and Henshall looked at the Self-Compassion Scale-Short-Form (SCS-SF), which was 5.69 ± 1.15 [16].  [30]. The rest of the studies reported SCS as an average of the total score, which ranged from 18-80.

Important Correlations
All included studies evaluated the correlation of self-compassion with other important psychosocial outcomes such as depression, anxiety, stress, resilience, shame, quality of life, and other outcomes as shown in Table 2. Nine studies evaluated the correlation between self-compassion and depression [16,18,[20][21][22][23]26,29,33]. All studies found that a higher self-compassion was correlated with lower levels of depression in individuals with a medical illness. Four of these studies looked specifically at self-compassion scores in relation to the Patient Health Questionnaire-9 (PHQ-9) scores, which found that increased SCS scores were associated with decreased levels of PHQ-9 scores [21,22,26,33]. Moreover, two studies looked at selfcompassion in relation to the Hospital Anxiety and Depression Scale (HADS) questionnaire and demonstrated similar results [16,18]. Five studies looked at the correlation between self-compassion and anxiety, two of which were previously discussed using the HADS questionnaire. The rest of the three studies used different types of questionnaires but revealed that self-compassion scores were negatively correlated with anxiety [23,29,33].
Two studies looked at the relationship between self-compassion and shame [16,30]. One study showed that as self-compassion levels increased, shame decreased, while the other study showed no correlation between self-compassion and shame. Four studies looked at the correlation between self-compassion and quality of life [19,21,28,30]. Two studies showed that increased self-compassion improved quality of life, while two studies showed that higher levels of self-compassion correlate with any improvement [19,21,28,30]. Four studies investigated correlations between self-compassion and levels of stress [21][22][23]26]. Three of the four studies looked at self-compassion and Diabetes Distress Scores (DDS-17) and demonstrated that as selfcompassion increased, DDS decreased [21,22,26]. The other study demonstrated that higher self-compassion levels correlated with lower stress levels [23]. One study by Hurwit, Yun, and Ebbeck demonstrated that higher self-compassion is associated with higher resilience [28]. Furthermore, the self-compassion interventions are likely to be more effective with women, as they have previously been reported to have lower self-compassion levels than men [6]. Lastly, two studies investigated the link between self-compassion and adherence behavior [19,30]. Skelton et al. demonstrated that self-compassion was not associated with increased adherence behavior in HIV patients [30]. On the other hand, Dowd and Jung exhibited that selfcompassion at baseline was able to predict adherence to a gluten-free diet in celiac patients [19].

Clinical Outcomes
Only two studies investigated the effect of self-compassion on clinical outcomes specifically for diabetes with HbA1c and blood glucose levels, as shown in   In previous studies, higher levels of self-compassion have been linked to lower levels of stress, depression, and anxiety [34,35]. For example, a group of healthy females was subjected to a high-stress task, and those who were trained in self-compassion were found to have lower sympathetic nervous system response compared to the placebo group [36]. Similarly, in another study that investigated the relationship between self-compassion and depression in a German cohort of 2,404 healthy individuals, Korner and colleagues used the PHQ-9 questionnaire to determine depression symptoms and demonstrated that increased depression correlated with lower SCS total scores and subscores [37]. After a logistic regression was performed and variables were adjusted, the model showed that 23% of the variance in depression symptoms was explained by SCS [37]. Therefore, self-compassion was shown to be a protective factor against depression [37]. Self-compassion has been demonstrated to have great implications on psychological wellbeing in chronic diseases given the contribution of psychological parameters in the exacerbation of diseases.
Another important role of self-compassion in medical disease management is related to the increase in health-promoting behaviors. Self-management behaviors have long been a central component of symptom management and improving disease trajectory and outcomes in chronic conditions [38]. The recent 2019 novel coronavirus pandemic has affected all spheres of health. Mental health has been no exception and resultant cognitive distress, anxiety, and fear of being out in public have been reported [39]. Selfcompassion may prove to be quite an effective tool in managing these.
Previous studies have also demonstrated an association between self-compassion and self-management behaviors [3,4]. A meta-analysis by Sirois pooled 3,252 individuals across 15 studies and found that higher self-compassion was positively correlated to better engagement in health-promoting behaviors for chronic diseases [40]. These behaviors included better stress management, adherence to medication, lifestyle modifications, and improved sleep quality. This was consistent with data in our review, which demonstrated that in one of the two studies, self-management behaviors increased with increasing self-compassion.
Self-compassion-based training and interventions have been linked to better clinical outcomes in individuals experiencing medical illnesses. These interventions include compassion-focused therapy (CFT) and compassionate mind training (CMT) [41]. Previous studies have demonstrated success in these targeted interventions in providing acceptance and care for oneself by practicing health-promoting behaviors [42]. A review by Leaviss and Uttley, which included 14 studies, demonstrated that CFT is an effective intervention particularly in individuals prone to high self-criticism [43]. Although limited data exist in the role of selfcompassion in improving clinical outcomes, there have been promising outcomes in the effect of selfcompassion therapy in the improvement of treatment of medical conditions [44,45]. As shown by two studies in this review, self-compassion intervention compared to placebo can truly affect clinical outcomes in diabetes parameters such as HbA1c and blood glucose levels [22,24].
In this review, the studies examined the effect of self-compassion on clinical diabetic outcomes in the shortterm, for a period of three months. There is a growing body of evidence that self-compassion interventions need to be provided through multiple sessions for at least 12 weeks to yield any differences in both psychosocial and clinical outcomes [46]. A study by Philips and Hine underlined the importance of a multisession self-compassion intervention to impact self-management behaviors, improve psychological outcomes, and enhance physical health [46]. Thus, combining a self-compassion intervention with multiple sessions for a duration of more than six months can enhance the magnitude of self-compassion in its influence on disease management of individuals with medical illnesses.
The introduction of self-compassionate intervention is only the start in this realm; however, the practice of self-compassion by healthcare workers is necessary to maximize the impact of such an intervention. Studies have demonstrated that workers in the healthcare industry can affect the behaviors of patients [47]. Therefore, it is crucial to foster a compassionate setting to promote better communication, understanding, and disease management in patients [48,49]. This ongoing training and support will cultivate an environment that will enhance the patients' sense of self-efficacy and compassion toward themselves and thus improve their attitude towards engaging in health-promoting behaviors [50].
This study has several limitations. Firstly, the study only included publications in the English language. Secondly, there was significant variability in data presentation between studies. For example, the questionnaires used for each study varied. Moreover, even though the same self-compassion questionnaire was used, each study had calculated the scores differently by removing various items from the questionnaire. As such, this hindered our ability to conduct a meta-analysis and grasp the extent of the effects of self-compassion on psychosocial and clinical outcomes. Finally, only two of the included studies reported the role of self-compassion intervention on clinical outcomes, thus limiting our ability to identify whether using a self-compassion program can affect clinical outcomes and disease trajectory in medically ill individuals.

Conclusions
In conclusion, this systematic review highlights the role of self-compassion with respect to its correlation and effect on psychosocial outcomes. Moreover, albeit the small sample size, this study showed the significance of the integration of a self-compassion program in the management of medical illnesses. Therefore, there is a dire need for the use of self-compassion as a tool to tackle the treatment of diseases. Further studies are needed to evaluate long-term outcomes of a self-compassion-based intervention to highlight its importance in the role of disease management.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.