Mindfulness-Based Stress Reduction Equivalent to Escitalopram for Treatment of Anxiety Disorders
Hoge et al reported in JAMA Psychiatry (2022) that in a randomized clinical trial of 276 adults with anxiety disorders, 8-week treatment with mindfulness-based stress reduction (MBSR) was noninferior to escitalopram. The “MBSR is a manualized 8-week protocol with weekly 2.5-hour long classes, a day-long retreat weekend class during the fifth or sixth week, and 45-minute daily home practice exercises…. Qualified instructors taught the theory and practice of several forms of mindfulness meditation, such as breath awareness (focusing attention on the breath and other physical sensations), a body scan (directing attention to one body part at a time and observing how that body part feels), and mindful movement (stretching and movements designed to bring awareness to the body and increase interoceptive awareness)….Escitalopram was initiated at 10 mg daily orally and increased to 20 mg daily at week 2 if well tolerated or delayed if not.” The investigators concluded that “mindfulness-based stress reduction was a well-tolerated treatment option with comparable effectiveness to a first-line medication for patients with anxiety disorders.”
Mindfulness-Based Cognitive Therapy May Improve Depression More Than Fitness Intervention
In a study by researcher Stuart Eisendrath and colleagues, people with treatment-resistant unipolar depression responded better to an intervention that combined mindfulness training with cognitive therapy than to one that included exercise, nutrition counseling, and music therapy.
The 173 participants had failed to respond to at least two different antidepressant medications. During the study period, all participants were taking an antidepressant, but none were receiving other types of therapy.
After eight weeks, the mindfulness-based cognitive therapy (MBCT) group showed greater improvement in their depression symptoms than the exercise and nutrition group. Of the MBCT group, 29.58% had a large reduction in symptoms, while 17.19% of the comparison group showed a similarly large reduction in symptoms.
A subgroup of the participants also received functional magnetic resonance imaging (fMRI) as part of the study. While completing a task related to emotional working memory, the MBCT group showed enhanced activation of the dorsal lateral prefrontal cortex (to levels seen in non-depressed people). This area is related to executive control of depression and memory functions. The MBCT group also showed reduced activation of the ventral lateral prefrontal cortex compared to the comparison group. Members of the MBCT whose depression symptoms had improved also showed better regulation of the amygdala during the task compared to the exercise and nutrition group.
The research was presented at the 2016 meeting of the American Psychiatric Association.
Mindfulness Therapy Improves Anxiety in Youth with a Bipolar Parent
Children of parents with bipolar disorder are prone to anxiety and emotional dysregulation, but treating these symptoms with antidepressants can provoke symptoms of mania. Thus, non-pharmacological treatements for anxiety and depression are needed. A recent study by Melissa DelBello found that twelve weeks of mindfulness-based cognitive therapy improved symptoms of anxiety and mood dysregulation in 20 youth with a bipolar parent. DelBello used functional magnetic resonance imaging (fMRI) to observe that the therapy increased activation of brain structures related to emotion and sensing. Amygdala activation differed between those with anxiety and those with mood dysregulation, suggesting that the therapy’s effect was on regions that modulate the amygdala, including prefrontal and insular regions, rather than on the amygdala itself.
Music, Mindfulness and Exercise Improve Brain Functioning
Psychiatrists should take the lead in endorsing general wellness and encouraging healthy behaviors, says researcher James Hudziak. He suggests that opportunities to practice music, mindfulness, and exercise should be made available to all school children to increase brain health, and that more intensive efforts are necessary for children in families that are at risk for mood and behavioral difficulties or in children who show some dysfunction in these areas. Hudziak has implemented a statewide program in Vermont that encourages families to engage in these healthy practices.
Hudziak and colleagues analyzed brain scans of 232 children ages 6 to 18, looking for relationships between cortical thickness and musical training. They found that practicing an instrument such as the piano or violin increased working memory, gray matter volume in the brain, and the ability to screen out irrelevant noise. Practicing mindfulness increased white matter volume and reduced anxiety and depression. Exercise also increased brain volume and neuropsychological abilities.
Now Hudziak urges parents to advocate for the teaching of music, mindfulness, and exercise in schools as a way of improving general health, especially since music and gym are often the first programs to be cut when schools face budget shortages. Hudziak suggests that opportunities for athletics should be provided to all children, independent of their skill level, rather than only for the best athletes who “make the team.” Intramural teams should be open to all children, including those with less ability or minimal athletic skills. Exercise, teamwork, and friendships benefit all children.
For more information about the programs Hudziak implemented in Vermont, use the internet to search for the Vermont Family Based Approach, see his book Developmental Psychopathology and Wellness: Genetic and Environmental Influences, or call the University of Vermont Medical Center at (802)847-0000 or (800)358-1144.
Another tool that may be useful to parents of children aged 2 to 12 who are at risk for mood disorders is our Child Network, a secure online portal where parents can complete quick weekly ratings of their child’s mood and behavior, which is then graphed over time and can be used to show the child’s doctors how his or her symptoms are fluctuating and how well any treatment is working.
Mindfulness Interventions May Reduce Substance Use and Cravings
A 2014 meta-analysis of the literature to date on mindfulness-based interventions (MBIs) for substance use disorders suggests that these interventions can reduce consumption of alcohol, cocaine, amphetamines, marijuana, cigarettes, and opiates, compared to several types of controls. The research by Alberto Chiesa and Alessandro Serretti, published in the journal Substance Use and Misuse, includes 24 studies published before 2012. The authors also found some evidence that MBIs are associated with reduced craving and increased mindfulness. Most of the studies included in the meta-analysis were small, so their generalizability is limited.
A 2014 article by S. Bowen and colleagues in the journal JAMA Psychiatry compared mindfulness-based relapse prevention with standard relapse prevention and treatment as usual for people recovering from substance abuse. Mindfulness-based relapse prevention combines the cognitive behavioral approach of standard relapse prevention with MBIs that have been successful in other studies.
Bowen et al. found that both standard relapse prevention and mindfulness-based relapse prevention lowered the risk of relapse and reduced days of substance use at 6 months, compared to treatment as usual. The standard treatment delayed first drug use, but the mindfulness intervention decreased use at the 12-month mark compared to both standard relapse prevention and treatment as usual.
Psychotherapy Prevents Recurrence of Depression
New research shows that psychotherapy lowers the risk of relapse in unipolar major depression more than “treatment as usual” does, and also heads off depression in children at high risk.
At the 2013 meeting of the American Psychiatric Association, researcher Pim Cuijpers reviewed 32 trials of cognitive behavior therapy, intensive behavioral therapy, and problem solving therapy used for the prevention of depression and found that these therapies were associated with a 21% lower risk of relapse compared to treatment as usual.
There were five critical elements that made these therapies useful: they supported coping with depression, and they included exercise, mindfulness, internet-based cognitive behavior therapy, and problem solving.
Among those who presented at the meeting, Greg Clarke of Kaiser Permanente, Oregon discussed an 8-week course on coping with stress given to a group of adolescents (aged 14 to 16) who had four times the normal risk of developing depression because each had a parent with depression. Clarke found a significant reduction in depression among the adolescents who received therapy compared to controls.
Insomnia can be a precursor to a first depression or to recurrent depression. Cognitive behavior therapy was more effective in improving sleep than a comparative sleep hygiene course.
Researcher Judy Garber presented data showing that cognitive behavior therapy was effective in 13- to 17-year-olds who had a parent with depression and had themselves had a prior depression or were currently sub-syndromal. The effect of the therapy was only significant if the parent was not depressed at intake.
Meditation Improves Depression and Stress in Adolescents
A recent study in the UK compared students whose schools instituted the 9-week international Mindfulness in Schools Program (MiSP) curriculum to those who were taught a standard curriculum. Students at schools with MiSP were taught techniques for sustaining attention aimed at changing their thoughts, actions, and feelings.
Students who participated in MiSP training had fewer depressive symptoms immediately after the training and three months later. They also reported lower stress and greater well-being at follow-up. Those students using the techniques they learned in the program more consistently had better scores for depression, stress, and well-being than their peers who used the techniques less often. The study by Kuyken et al., which was published in the British Journal of Psychiatry in 2013, included 522 students between the ages of 12 and 16.
Psychological well-being has been linked to better learning and performance in school, in addition to better social relationships. Researchers suggested that because this kind of mindfulness training is designed to help students deal with everyday stressors and experiences, it has benefits for all students, regardless of their level of well-being.
Meditation Improves Mood and White Matter Integrity
New research shows that regular meditation in the form of mindfulness training improves both mood and measures of white matter (axon tract) integrity and plasticity in the anterior cingulate cortex (a key node in the brain network modulating self-regulation).
This research by Tang et al. published in the Proceedings of the National Academy of Sciences in 2012 was a continuation of the same research group’s investigation of integrative mind-body training (IMBT), a type of mindfulness training that incorporates increased awareness of body, breathing, and attention to external instructions meant to induce a state of balanced relaxation and focused attention. In a previous Tang et al. study comparing participants who received IMBT training with a control group who spent the same amount of time doing relaxation training, the participants who practiced IMBT for five days (20 minutes/day) had better scores on measures of attention, anxiety, depression, anger, fatigue, and energy. In another study the researchers found that four weeks of IMBT (30 minutes/day) increased fractional anisotrophy (FA) in white matter areas involving the anterior cingulate cortex, while four weeks of relaxation training did not bring about any effect on white matter. Decrease in FA is a part of aging. The four weeks of IMBT also decreased axial and radial diffusivity, suggesting better alignment of axons along white matter tracts.
In the most recent study, two weeks of IMBT (30 minutes/day) produced a reduction in axial diffusivity, but not effects on fractional anisotrophy or radial diffusivity, suggesting that the reduced axial diffusivity leads to the other changes seen with longer IMBT.
Editor’s Note: In those with unresolved problems with anxiety and depression, regular 20-30 minutes/day mindfulness practice may have beneficial effects not only on mood, but also on central nervous system structures. Mindfulness training involves focused attention on sequentially different parts of the body leading to exclusive focus on the physical aspects of breathing in and out. Intruding thoughts are recognized, but let go as trivial, passing interruptions, and focus is returned to the body and breathing. The aim is to clear the mind of its usual ideas, thoughts, and worries by continually refocusing on breathing. It takes practice to achieve, but regular mindfulness training can be a helpful addition to pharmaco- and psychotherapy.
It is also noteworthy that mindfulness training is one of the processes that helps elongate the ends of each strand of DNA, called telomeres. Telomeres shorten with aging, stress, and episodes of depression, and short telomeres lead to a variety of adverse medical consequences.
