A Three-Arm Randomized Clinical Trial Comparing the Efficacy of a Mindfulness-Based Intervention with an Active Comparison Group and Fluoxetine Treatment for Adults with Generalized Anxiety Disorder

Investigating the effects and efficacy of self-compassion intervention on generalized anxiety disorders

BACKGROUND

Generalized anxiety disorder (GAD) is the least successfully treated anxiety disorder. This clinical trial investigated the effects and efficacy of a novel self-compassion intervention in GAD.

METHODS

A total of 75 GAD patients were assigned to a self-compassion intervention group (n = 25), a mindfulness intervention group (n = 25), or a treat-as-usual group (n = 25). Patients in the two active groups received eight intervention sessions in two weeks in addition to usual treatment i.e., pharmacotherapy. Primary outcomes were anxiety and worry, assessed at pre-intervention, post-intervention, and three-month follow-up. Secondary outcomes included depression, sleep, as well as self-compassion and mindfulness.

RESULTS

Both the self-compassion and mindfulness intervention induced a more rapid decrease in anxiety and depression than pharmacological treatment alone with excellent response and remission rate. Self-compassion intervention also induced a more rapid improvement in sleep quality compared to mindfulness intervention and pharmacological treatment alone. We also presented a mechanism for the self-compassion intervention in which decreased anxiety led to improvement in sleep quality. There was also a higher pleasure, acceptance, and willingness to re-attend in the self-compassion compared to the mindfulness intervention.

LIMITATIONS

This study was single blinded and nonrandomized which may bring risks of bias.

CONCLUSIONS

Overall, we provided novel evidence that self-compassion intervention is an alternative psychotherapy for GAD with excellent response and acceptability.

Update on treatments for anxiety-related disorders

PURPOSE OF REVIEW

This review examines recent evidence that informs the treatment of anxiety-related disorders.

RECENT FINDINGS

In addition to selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines, agomelatine has demonstrated efficacy in treating generalized anxiety disorder (GAD). Other novel products, such as ketamine, psilocybin and cannabidiol, are in the process of gathering evidence in support of the treatment of anxiety disorders. In psychological therapy, various psychological treatments for anxiety disorders, such as mindfulness-based intervention, acceptance and commitment therapy, psychodynamic therapy, emotion-focused therapy and dialectical behavioural therapy, have been tried. Still, most therapies have not proven superior to cognitive behavioural therapy (CBT). In very preliminary findings: Repetitive transcranial magnetic stimulation (rTMS) was effective in GAD; transcranial direct current stimulation (tDCS) was effective for social anxiety disorder (SAD) and GAD and augmented exposure therapy for specific fears. Internet and mobile-based interventions have comparable efficacy to face-to-face therapy.

SUMMARY

Pharmacotherapy of anxiety disorders is expanding to novel products. Despite trying other psychological therapies for anxiety disorders, most therapies were comparable to but not superior to CBT. rTMS and tDCS were also used and show early promise for GAD, but further studies are needed. Most internet or mobile app based psychological therapies were based on CBT, and some can be considered as alternatives to in-person face-to-face therapy.

Mechanisms of improvement in generalized anxiety disorder: A mediation and moderated mediation analysis from a randomized controlled trial

BACKGROUND

Generalized anxiety disorder (GAD) is associated with the lowest treatment response rate among all anxiety disorders. Understanding mechanisms of improvement may help to develop more effective and personalized treatments.

AIM

The objective of the study was to investigate different improvement mechanisms in the treatment of individuals diagnosed with GAD.

DESIGN

We reported data from a randomized controlled trial that evaluated three different GAD treatments (mindfulness-based intervention, BMT; fluoxetine, FLX; and an active comparison group, QoL) for 8 weeks.

METHOD

Mediation analyses were performed evaluating the association between worry symptoms at baseline and anxiety scoring at the endpoint, considering self-compassion or mindfulness or its dimensions at mid-treatment as mediators for the whole sample (assessing GAD improvement mechanism) and the different interventions as moderators.

RESULTS

Contrary to mindfulness state scoring (C = .06; 95% CI = -.05 to .20), self-compassion (C = .11; 95% CI = .01 to .28) and non-judgement of inner experience (C = .10; 95% CI = .004 to .21) mediated the association between worry symptoms at baseline and anxiety at the endpoint. When comparing BMT to FLX, the intervention modality did not moderate these associations.

CONCLUSION

Self-compassion and non-judgement of inner experience seem to be essential targets in GAD treatment, contrary to the mindfulness state itself. Although no difference was found considering the intervention modality, future research may assess how to boost these dimensions in specific treatments for GAD.

Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial

Importance

Anxiety disorders are common, highly distressing, and impairing conditions. Effective treatments exist, but many patients do not access or respond to them. Mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR) are popular and can decrease anxiety, but it is unknown how they compare to standard first-line treatments.

Objective

To determine whether MBSR is noninferior to escitalopram, a commonly used first-line psychopharmacological treatment for anxiety disorders.

Design, Setting, and Participants

This randomized clinical trial (Treatments for Anxiety: Meditation and Escitalopram [TAME]) included a noninferiority design with a prespecified noninferiority margin. Patients were recruited between June 2018 and February 2020. The outcome assessments were performed by blinded clinical interviewer at baseline, week 8 end point, and follow-up visits at 12 and 24 weeks. Of 430 individuals assessed for inclusion, 276 adults with a diagnosed anxiety disorder from 3 urban academic medical centers in the US were recruited for the trial, and 208 completed the trial.

Interventions

Participants were 1:1 randomized to 8 weeks of the weekly MBSR course or the antidepressant escitalopram, flexibly dosed from 10 to 20 mg.

Main Outcomes and Measures

The primary outcome measure was anxiety levels as assessed with the Clinical Global Impression of Severity scale (CGI-S), with a predetermined noninferiority margin of -0.495 points.

Results

The primary noninferiority sample consisted of 208 patients (102 in MBSR and 106 in escitalopram), with a mean (SD) age of 33 (13) years; 156 participants (75%) were female; 32 participants (15%) were African American, 41 (20%) were Asian, 18 (9%) were Hispanic/Latino, 122 (59%) were White, and 13 (6%) were of another race or ethnicity (including Native American or Alaska Native, more than one race, or other, consolidated owing to low numbers). Baseline mean (SD) CGI-S score was 4.44 (0.79) for the MBSR group and 4.51 (0.78) for the escitalopram group in the per-protocol sample and 4.49 (0.77) vs 4.54 (0.83), respectively, in the randomized sample. At end point, the mean (SD) CGI-S score was reduced by 1.35 (1.06) for MBSR and 1.43 (1.17) for escitalopram. The difference between groups was -0.07 (0.16; 95% CI, -0.38 to 0.23; P = .65), where the lower bound of the interval fell within the predefined noninferiority margin of -0.495, indicating noninferiority of MBSR compared with escitalopram. Secondary intent-to-treat analyses using imputed data also showed the noninferiority of MBSR compared with escitalopram based on the improvement in CGI-S score. Of patients who started treatment, 10 (8%) dropped out of the escitalopram group and none from the MBSR group due to adverse events. At least 1 study-related adverse event occurred for 110 participants randomized to escitalopram (78.6%) and 21 participants randomized to MBSR (15.4%).

Conclusions and Relevance

The results from this randomized clinical trial comparing a standardized evidence-based mindfulness-based intervention with pharmacotherapy for the treatment of anxiety disorders found that MBSR was noninferior to escitalopram.

Trial Registration

ClinicalTrials.gov Identifier: NCT03522844.

Effects of group mindfulness-based cognitive therapy and group cognitive behavioural therapy on symptomatic generalized anxiety disorder: a randomized controlled noninferiority trial

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) is a promising alternative treatment for generalized anxiety disorder (GAD). The objective of this study was to examine whether the efficacy of group MBCT adapted for treating GAD (MBCT-A) was noninferior to group cognitive behavioural therapy (CBT) designed to treat GAD (CBT-A), which was considered one of first-line treatments for GAD patients. We also explored the efficacy of MBCT-A in symptomatic GAD patients compared with CBT-A for a variety of outcomes of anxiety symptoms, as well as depressive symptoms, overall illness severity, quality of life and mindfulness.

METHODS

This was a randomized, controlled, noninferiority trial with two arms involving symptomatic GAD patients. Adult patients with GAD (n = 138) were randomized to MBCT-A or CBT-A in addition to treatment as usual (TAU). The primary outcome was the anxiety response rate assessed at 8 weeks after treatment as measured using the Hamilton Anxiety Scale (HAMA). Secondary outcomes included anxiety remission rates, scores on the HAMA, the state-trait anxiety inventory (STAI), the Hamilton Depression Scale (HAMD), the Severity Subscale of the Clinical Global Impression Scale (CGI-S), and the 12-item Short-Form Health Survey (SF-12), as well as mindfulness, which was measured by the Five Facet Mindfulness Questionnaire (FFMQ). Assessments were performed at baseline, 8 weeks after treatment, and 3 months after treatment. Both intention-to-treat (ITT) and per-protocol (PP) analyses were performed for primary analyses. The χ2 test and separate two-way mixed ANOVAs were used for the secondary analyses.

RESULTS

ITT and PP analyses showed noninferiority of MBCT-A compared with CBT-A for response rate [ITT rate difference = 7.25% (95% CI: -8.16, 22.65); PP rate difference = 5.85% (95% CI: - 7.83, 19.53)]. The anxiety remission rate, overall illness severity and mindfulness were significantly different between the two groups at 8 weeks. There were no significant differences between the two groups at the 3-month follow-up. No severe adverse events were identified.

CONCLUSIONS

Our data indicate that MBCT-A was noninferior to CBT-A in reducing anxiety symptoms in GAD patients. Both interventions appeared to be effective for long-term benefits.

TRIAL REGISTRATION

Registered at chictr.org.cn (registration number: ChiCTR1800019150 , registration date: 27/10/2018).

A systematic review and meta-analysis of acceptance- and mindfulness-based interventions for DSM-5 anxiety disorders

This meta-analysis systematically reviewed the evidence on standardized acceptance-/mindfulness-based interventions in DSM-5 anxiety disorders. Randomized controlled trials examining Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy (MBCT), and Mindfulness-Based Stress Reduction (MBSR) were searched via PubMed, Central, PsycInfo, and Scopus until June 2021. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for primary outcomes (anxiety) and secondary ones (depression and quality of life). Risk of bias was assessed using the Cochrane tool. We found 23 studies, mostly of unclear risk of bias, including 1815 adults with different DSM-5 anxiety disorders. ACT, MBCT and MBSR led to short-term effects on clinician- and patient-rated anxiety in addition to treatment as usual (TAU) versus TAU alone. In comparison to Cognitive Behavioral Therapy (CBT), ACT and MBCT showed comparable effects on both anxiety outcomes, while MBSR showed significantly lower effects. Analyses up to 6 and 12 months did not reveal significant differences compared to TAU or CBT. Effects on depression and quality of life showed similar trends. Statistical heterogeneity was moderate to considerable. Adverse events were reported insufficiently. The evidence suggests short-term anxiolytic effects of acceptance- and mindfulness-based interventions. Specific treatment effects exceeding those of placebo mechanisms remain unclear. Protocol registry: Registered at Prospero on November 3rd, 2017 (CRD42017076810).