Meditation Equal to First-Line Medication for Anxiety

Mindfulness-based stress reduction (MBSR) is as effective at reducing anxiety as the antidepressant escitalopram, a first-line pharmaceutical treatment, new research shows.

“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders.

“Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, DC, told Medscape Medical News.

The findings were published online November 9 in JAMA Psychiatry.

Screening Recommended

Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.

Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.

Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Hoge.

The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.

Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.

The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.

Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.

The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Hoge.

Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of -0.07; 95% CI, -0.38 to 0.23; P = .65).

The lower end of the confidence interval (-0.38) was smaller than the prespecified noninferiority margin of -0.495, indicating noninferiority of MBSR compared with escitalopram.

Remarkable Results

“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”

The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports because that gives us two ways to look at the information,” said Hoge.

Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”

Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared to 15.4% in the MBSR group.

The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”

Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Hoge.

MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.

But online classes might work if “the exact same class,” including all its components, is moved online, she said.

MBSR is available in all major US cities, doesn’t require finding a therapist, and is available outside a mental health environment, for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Hoge.

A Time-Tested Intervention

Commenting for Medscape Medical News, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life, said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.

“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.”

He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”

Because most study participants were women and “men are anxious too,” Brown said he would like to see the study replicated “with a more diverse pool of participants.”

The study was supported by the Patient-Centered Outcomes Research Institute. Hoge and Brown have reported no relevant financial relationships.

JAMA Psychiatry. Published online November 9, 2022. Full text

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