Mindfulness-Based Stress Reduction & Pharmacotherapy for Anxiety - - PowerPoint PPT Presentation

Comparative Effectiveness of

Mindfulness-Based Stress Reduction & Pharmacotherapy for Anxiety

Elizabeth Hoge, MD

Associate Professor of Psychiatry Georgetown University Medical Center September 19, 2019

2

Elizabeth Hoge

• Has nothing to disclose.

Talk Outline

• What is Mindfulness Meditation?
• Why would it be used with Anxiety

Disorders?

• Why compare it to a medication?

Mindfulness Meditation is Becoming Very Popular

What is Mindfulness Meditation?

• 1. Self-regulation of attention - maintained on

immediate experience in the present moment (sensations, emotions, thoughts)

• 2. Adopt a particular orientation toward one’s

experiences in the present moment, characterized by curiosity, openness, and acceptance

Bishop et al, 2004, Clinical Psychol Sci Prac 11 (3): 230–241.

How does Mindfulness Meditation change thinking?

• Learn to be aware of thoughts and feelings as “merely

passing events of the mind rather than necessarily ….reflections of reality” (Ramel et al, 2004)

• More acceptance of “what
• ne cannot control”
• Avoid getting pulled into action or

absorbed in content of the thought

Example: Mindfulness Meditation to Treat Generalized Anxiety Disorder (GAD)

Psychiatric Diagnostic Criteria for GAD

• Worry that is difficult to Control
• 3 of these:

– Restlessness or feeling keyed up or on edge – Being easily fatigued – Difficulty concentrating or mind going blank – Irritability – Muscle tension – Sleep disturbance (difficulty falling asleep or staying asleep, or restless, unsatisfying sleep)

• Functional impairment and/or distress
• Not due to other disorder/medical condition

DSM-5. Washington, DC: American Psychiatric Association, 1994.

Mindfulness Meditation:

Why might it be helpful for GAD?

• Generalized Anxiety Disorder: Worrying serves an

avoidance function (Borkovec et al., 2004)

– patients worry to avoid experiencing negative emotions i.e. sadness, anger – Patients focus on the future rather than the present experience

• With Mindfulness, one focuses on

the present experience and accepting it (Roemer et al, 2006)

Lifetime Prevalence of Anxiety Disorders

Kessler et al Arch Gen Psychiatry. 2005 Jun;62(6):593-602.

Mindfulness-Based Stress Reduction (MBSR)

• Originally developed by Jon Kabat-Zinn and

colleagues at the Univ. of Massachusetts

• 8 weekly group sessions, 2.5 hour class with

mindfulness practices

• breath awareness
• hatha yoga
• body-scan
• 40 minutes daily mindfulness exercises at home
• one weekend day retreat

noticing mental events with curiosity, openness, acceptance

What does previous research show?

• Cochrane Database Systematic Review:

“Meditation therapy might hold some promise… for patients with anxiety disorders, however the scarcity of randomised controlled trials… demand caution...”

Cochrane Database Syst Rev. 2006 Jan25;(1):CD004998.

What does previous research show?

• Another review study noted:
• “mindfulness meditation could have a non-specific

effect compared to no treatment (such as a waiting list)… future studies should compare MM to a control group designed to be structurally equivalent to a meditation programme in terms of instructor attention, weekly and total duration…” (Chiesa et al 2010)

“Firm conclusions on the effects of meditation …cannot be drawn…special attention should be paid to developing studies that provide a more accurate assessment of the efficacy and effectiveness of meditation practices, both against standard therapies and against each other”

Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Publication No. 07-E010, June 2007

You mean, meditation versus medication?

Clinical Trial Requirements for Rigorous Methodology

• Randomized
• Controlled
• Blinding - we use single-blind raters for clinical symptoms
• Standard statistical analysis
• Multi-site coordination (i.e. interrater reliability)

Mindfulness-Based Stress Reduction (MBSR)

• 8 weekly group sessions, 2.5 hour class with

mindfulness practices

• breath awareness
• hatha yoga
• body-scan
• 40 minutes daily mindfulness exercises at home
• one weekend day retreat

noticing mental events with curiosity, openness, acceptance

TAME: Treatments for Anxiety: Meditation and Escitalopram

Georgetown, NYU, Massachusetts General, N=368

TAME: Treatments for Anxiety: Meditation and Escitalopram

Primary Outcome Measurement: Clinical Global Assessment of Severity by Blinded Clinician Assessors; Hypothesis: Non- Inferiority between Meditation and Drug Other Outcomes: Treatment satisfaction, side effect burden, sleep quality, occupational functioning

Input f from Patients a and o

• ther S

Stakeholders

Patient Panel

• Advised us on recruitment strategies: tear-off ads, decided against radio ads,

created interior bus ads, gym flyers, suggested social media sites (Instagram, etc)

• Advised us to measure the effects of treatment of different groupings of anxiety

symptoms such as disorder specific scales

• Advised us to have a possibility for study visits to be conducted over the phone,

if needed to be more convenient for patients

Stakeholder Panel (Healthcare systems, Payors, Private Practice,

Patient Advocacy)

• Asked us to consider that a history of trauma (even without PTSD) could have

an interaction effect in the treatment outcome - We added trauma experience questionnaires to capture these data

• Payor representative noted that effect of symptoms on work performance would

be important to measure

Thank you very much for your attention!