Generalized Anxiety Disorder Symptom Improvement Following Mindfulness-Based Stress Reduction in a General Hospital Setting

INTRODUCTION

Generalized Anxiety Disorder (GAD) is highly prevalent in primary care medical settings, often associated with disability, functional impairment, and increased health care utilization [1, 2]. Costs associated with GAD further increase with common medical and psychiatric comorbidities such as pain and/or depression [3]. Although patients suffering from GAD symptoms commonly present in general medical settings, recognition of GAD in such settings is poor and several barriers to specialty care exist [1]. Fortunately, cross-diagnostic intervention approaches such as Mindfulness-Based Stress Reduction (MBSR) are becoming increasingly available within the general hospital setting, simultaneously addressing comorbid complaints of chronic pain, insomnia, depression, and other anxiety disorders in addition to GAD symptoms.

Jon Kabat-Zinn developed Mindfulness-Based Stress Reduction (MBSR) at the University of Massachusetts (UMass) Medical School in 1979 for medical patients coping with the stress of chronic pain and illness or with stress-related physical symptoms. This eight-week program began as a hospital-based public health education course, in which MBSR instructors taught formal mindfulness meditation and yoga practices and assigned informal daily life practices according to a rigorous 30-hour curriculum. Although intensive, MBSR programs offered several practical advantages over traditional behavioral health and psychiatric treatment approaches: MBSR instructors without specialized mental health professional backgrounds could serve large groups of 20 to 40 diagnostically heterogeneous patients in one 8-week MBSR course cycle. As early outcome research demonstrated its effectiveness, particularly for the management of chronic pain [4, 5], subsequent randomized control trials established the efficacy of MBSR for chronic pain and other chronic medical diseases [6, 7]. MBSR effectively improved symptoms of anxiety and depression across various medical and psychiatric conditions, as evidenced by meta-analysis research consistently reporting medium effect sizes [7–9]. MBSR now appears as an intervention evaluated in comparative effectiveness research studies in the Substance and Mental Health Services Administration (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP).

MBSR might serve as an effective adjunct to traditional outpatient psychiatric services. Biegel and colleagues [10] randomized 102 adolescents with heterogeneous psychiatric diagnoses who were receiving standard psychiatric care in an outpatient setting to receive treatment as usual and MBSR or only treatment as usual. Psychiatric outpatients who received MBSR exhibited reduced symptoms of anxiety, depression, somatic distress, and sleep disturbance significantly more than the treatment-as-usual only control group receiving only standard of care medication and/or other mental health treatment. When MBSR was provided to psychiatric patients with past or current mood disorder diagnoses, patients reported decreased depression symptoms, trait anxiety, depressive beliefs (dysfunctional attitudes), and rumination following MBSR when compared to a non-randomized matched waitlist control group [11]. MBSR also appears a promising treatment alternative for anxiety disorder patients, with randomized control trials establishing efficacy for Social Anxiety Disorder [12] and for trans-diagnostic anxiety, depression, and insomnia symptom reduction among patients diagnosed with any one or a mixture of Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder [13]. Hoge et al. [14] conducted a randomized controlled trial delivering MBSR or an active stress management control intervention to patients diagnosed as GAD with structured clinical interviews. GAD patients randomized to MBSR exhibited comparable reductions in Hamilton Anxiety Scale symptom ratings compared to the active control group post-intervention, yet MBSR led to greater improvements on clinical severity and improvement clinician ratings and self-reported anxiety than the active control group. MBSR also was associated with greater reductions in subjective anxiety and distress and increased positive self-statements in response to a laboratory social stress challenge task when compared to the active stress management control group. Results from this study suggested that the documented clinical benefits of MBSR for GAD symptoms are not merely attention placebo effects and cannot be attributed solely to the general effects of standard stress management education. Thus, hospital-based MBSR programs may offer a desirable adjunctive or alternative treatment option for GAD patients presenting in medical settings.

Although MBSR appears promising for GAD patients presenting in the medical setting context, little research has examined whether GAD patients actually seek out and benefit from such MBSR programs when available. MBSR programs established in general hospital facilities typically serve a wide range of medical patients and do not target GAD as a specific clinical indication. Thus, patients suffering from GAD and their medical providers alike may not recognize such MBSR programs as a viable alternative or addition to specialty psychiatric care. Furthermore, randomized control trials conducted within the research context usually delivered MBSR to small and diagnostically homogeneous groups rather than to larger groups of hospital patients receiving MBSR for a myriad of reasons. The lack of such naturalistic setting research leaves uncertainty as to whether the MBSR-related GAD symptom reduction observed in controlled research generalizes to the medical setting context. In one notable exception, patients attending the original UMass Medical School MBSR program were screened for DSM-III-R diagnoses of GAD and/or panic disorder with a structured clinical interview [15]. Patients who screened positive for either or both anxiety disorders before MBSR reported significant reductions on anxiety measures designed for the general population (e.g., SCL-90-R) and on acute anxiety measures common to panic disorder research (e.g., Beck Anxiety Inventory, Fear Survey Schedule, Mobility Inventory for Agoraphobia) following the MBSR intervention. Importantly, follow-up research conducted with these same patients documented maintenance of observed improvement three years later [16]. Although GAD individuals were included, outcome measures designed to target symptoms that specifically characterize GAD, such as excessive and uncontrollable worry, were not used. It therefore has not been established whether MBSR directly impacts this key cognitive process central to the development and maintenance of GAD symptoms outside the controlled research context. MBSR emphasizes training in non-judgmental and present-centered awareness, which could counteract reactive mental loops of worry and/or rumination. Within the theoretical context of Metacognitive Therapy for GAD (MCT) [17], mindfulness meditation practice may serve to facilitate meta-cognitive capacity: over the course of meditation practice, individuals might identify underlying meta-cognitive negative beliefs that worry is dangerous while learning to relate to such erroneous beliefs as mere unreliable mental phenomena. The purpose of the current investigation therefore was twofold. First, MBSR participants enrolled in a large, established hospital MBSR program completed self-report measures of GAD specific symptoms and worry at the beginning of the MBSR course to reveal what proportion of patients seeking MBSR in this setting also presented with symptoms of GAD. Second, to examine whether such symptoms and worry reduced following MBSR, these MBSR patients were invited to repeat these measures during the final MBSR session. Importantly, a widely used standardized measure of worry was added to symptom measures to assess excessive and uncontrollable worry directly. This research design compliments previous controlled outcome investigations conducted in artificial research settings by examining whether clinically severe GAD symptoms and worry, if present at the outset, improve following MBSR when delivered in its original naturalistic context.

MATERIALS AND METHODS

RESULTS

DISCUSSION

Results from this survey investigation indicated that 40% of this sample reported moderate to severe GAD symptoms during the first MBSR session, scoring above the GAD-7 cutoff indicating likelihood of GAD diagnosis. It is unclear whether this high GAD rate reflects this particular hospital setting population generally, whether patients and/or providers within this community consider MBSR a desirable intervention approach for GAD, or whether GAD symptoms simply accompanied other comorbid medical or psychiatric conditions for which these patients enrolled in the MBSR program. Consistent with controlled research findings, statistically significant reductions on all measures for the sample as a whole, as well as for those participants reporting moderate to severe GAD at the beginning of the MBSR program, suggest improved acute anxiety, stress, generalized anxiety, and worry symptoms across participants. For the full completer sample, such statistically significant reductions were accompanied by medium effect sizes (Cohen’s d ranging from 0.425 to 0.822), suggesting that the degree of improvement on these outcome measures was comparable to the effects reported in randomized trials appearing in the larger medical literature [7]. The large effect sizes found for the subsample of participants indicating moderate to severe GAD (Cohen’s d ranging from 0.709 to 1.950) suggest that MBSR might offer pronounced benefit for those patients seeking MBSR for GAD symptoms.

These reported symptom reductions appear clinically significant as well. Of those 19 participants with GAD at the outset who provided post-intervention data, 15 recovered to the point of scoring in the minimal to mild rage at the end of the MBSR program. Moreover, means on standardized measures of acute anxiety, stress, and worry for these participants were more than one standard deviation above published normative population means during the first MBSR session, yet fell within one standard deviation of nonclinical sample norms during the final MBSR session ([18] for DASS scales; [25] for PSWQ). When specific clinical significance criteria were applied to PSWQ and DASS-21 post-intervention scores, almost half of the moderate to severe GAD participants reported reliable clinical improvement on the PSWQ, and over one third demonstrated recovery on this worry measure. This finding suggests that worry reduction may be an important clinical target when evaluating the clinical effectiveness of MBSR for GAD. Approximately half of the moderate to severe GAD participants also reported recovery on acute anxiety and stress symptom measures, suggesting that clinically significant general symptom reduction beyond that measured by the GAD-7 also occurred.

MBSR therefore may be an effective addition or alternative to specialty psychiatric services in the amelioration of worry, GAD, and related symptoms. Observed PSWQ reductions in the current study suggest that patients may experience reduced excessive and/or uncontrollable worry as a component of GAD related symptom improvement. MBSR may be especially indicated for GAD because of its demonstrated effectiveness with other common comorbid conditions, such as depression, other anxiety disorders, insomnia, and chronic pain [7]. Case studies and preliminary research has documented such trans-diagnostic symptom improvement for GAD individuals following MBSR [26, 13]. The original MBSR protocol has been adapted specifically for the prevention of major depressive disorder relapse, resulting in Mindfulness-Based Cognitive Therapy (MBCT) [27]. Controlled research since demonstrated the efficacy of MBCT for the prevention of depressive relapse (see [27] for a review), and preliminary outcome research also supports MBCT for the treatment of panic disorder and GAD [28–31]. However, MBCT is a form of specialty mental health care, delivered by a trained mental health professional with specialized training in cognitive-behavior therapy as well as MBCT. GAD patients presenting within the general medical setting are more likely to have access to MBSR programs than to MBCT, and the current investigation suggests that the original MBSR curriculum delivered in this setting also may be indicated for GAD.

Nevertheless, several limitations of the current research warrant consideration. Although naturalistic designs conducted within “real world” clinical contexts maximize external validity, the lack of experimental control provided by randomized control trials prevents concluding that MBSR caused the changes observed in this study. Furthermore, the current design relied on a self-report screening measure to determine GAD diagnosis and severity, and no independent corroboration of diagnostic status was conducted. It is therefore unclear how many participants would have qualified for GAD diagnosis with structured clinical interview procedures and to what degree clinical symptom improvement would have been observed by trained clinical assessors. In addition, due to the lack of inclusion and exclusion criteria, some participants also reported concurrent medication and/or therapy. It therefore cannot be determined whether such additional interventions were responsible for observed improvements among those participants. It was also unclear whether patients receiving concurrent psychotherapy received cognitive-behavioral therapy or similar skills-based therapy versus supportive talk therapy. If patients were learning related skills in concurrent therapy, the specific effects of MBSR might be especially difficult to interpret. Another study limitation involves the lack of post-intervention data from 22 of the original 65 participants. This attrition rate far exceeds the 11% dropout rate of this particular MBSR program, suggesting that some participants simply decided not to complete assessment measures during the final MBSR session. This low rate of post-intervention measure completion also raises concerns that some participants could have experienced adverse effects during the course of MBSR, but such effects were not detected because adverse effects were not monitored in the current study. Regardless of the reason, no means for determining how these participants would have scored on outcome measures at the end of the intervention exist, therefore limiting conclusions that can be drawn. On a related note, longitudinal follow-up data were not collected after the final MBSR session, failing to assess whether these results maintained beyond post-intervention. Given the inherent trade-off between internal and external validity, future carefully controlled research to establish the efficacy of MBSR for GAD as well as additional naturalistic research to examine effectiveness in applied clinical contexts are needed. Finally, although conducted within a naturalistic hospital setting, these results may not generalize to other regions of the country with different cultural and sociodemographic population characteristics. Indeed, the MBSR program evaluated in the current study is located in northern California’s Silicon Valley, representing one of the highest cost of living regions in the nation. Certain ethnic minority groups, including African American and Hispanic or Latino individuals, were not represented in the current sample. Although preliminary research suggests that MBSR also may be effective in ethnically diverse, low-income, inner-city clinic settings [32, 33], such research has not examined generalized anxiety symptom prevalence and symptom improvement specifically.

Although MBSR courses in the general hospital setting are provided to large, diagnostically heterogeneous patient groups by instructors without specialized mental health training, such programs might offer a valuable resource to GAD patients presenting in medical settings. The high rate of GAD reported at the beginning of MBSR in this sample suggests that MBSR may be acceptable to many such patients. The reported symptom reduction following MBSR in this investigation supports its effectiveness, at least for those patients who repeated the assessment measures during the final session. Future controlled research establishing the efficacy and effectiveness of MBSR for GAD as well as practical research that examines MBSR patient access and acceptability are needed to advance empirical knowledge in this area further.

CONFLICT OF INTEREST

The author has no conflict of interest to report.