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Mindfulness-based stress reduction non-inferior to escitalopram for anxiety disorders

Mindfulness-based stress reduction provides a non-inferior reduction in anxiety levels compared to treatment with escitalopram

Mindfulness-based stress reduction (MBSR) techniques are able to decrease anxiety levels to a similar extent as with treatment using the antidepressant escitalopram according to the findings of a randomised, controlled trial by US researchers.

Anxiety is a common mental health disorder, and it has been estimated that globally, in 2017 there were 284 million individuals affected by an anxiety disorder. Antidepressant drugs are effective for generalised anxiety disorders as highlighted in a 2019 network meta-analysis and which found that duloxetine and escitalopram showed better efficacy than other agents. Alternatives to pharmacotherapy include mindfulness-based stress reduction and cognitive behavioural therapy, with a 2021 systematic review concluding that mindfulness-based interventions produced short-term anxiolytic effects. Whilst both pharmacological and non-pharmacological interventions appear to be effective, the relative efficacy of these interventions has not been directly compared. As a result, in the present study, the US team undertook a randomised trial of MBSR versus escitalopram and which is currently approved for the management of social and generalised anxiety disorder.

The researchers enrolled adults aged 18 to 75 with a current diagnosis of generalised anxiety, social anxiety or panic disorder and randomised them 1:1 to either 8 weeks of MBSR or escitalopram 10 to 20 mg daily. The primary outcome was the change in anxiety levels as measured on the Clinical Global Impression of Severity Scale (CGI-S) which assesses symptoms on a 7-point scale, with higher scores indicative of more severe illness. This was assessed at baseline and then after 4 and 8 weeks. The MBSR included a weekly 2.5-hour class, and a 45-minute daily home practice exercise and escitalopram was dosed at 10 mg daily but could be increased to 20 mg daily if tolerated. The researchers set a non-inferiority margin of -0.495 for the difference in CGI-S score between the two groups, i.e., if this were to be exceeded then one of the interventions would be deemed more effective.

Mindfullness-based stress reduction and change in anxiety score

A total of 276 participants with a mean age of 33 (75% female) were included and randomised to escitalopram (140) or MBSR and the mean baseline CGI-S scores were similar (4.44 vs 4.51).

After 8 weeks of therapy, the CGI-S scores reduced by 1.35 and 1.43 in the MBSR and escitalopram groups respectively. The difference -0.07 (95% CI -0.38 to 0.23, p = 0.65) was not significant and with the lower bound of the 95% confidence interval below the pre-defined margin for non-inferiority (i.e., -0.495) not reached, the two interventions were essentially not different.

The authors concluded that given how both interventions were non-inferior, the study provided evidence to support the use of mindfulness meditation as an evidence-based treatment option for patients with anxiety disorder.

Hoge EA et al. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry 2022

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