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Original Investigation
November 9, 2022

Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychiatry, Georgetown University Medical Center, Washington, DC
  • 2Caen University Hospital & UNICAEN, INSERM, U1237, PhIND, NEUROPRESAGE Team, Caen, France
  • 3Medstar Health Research Institute, Hyattsville, Maryland
  • 4Massachusetts General Hospital, Department of Psychiatry, Harvard Medical School, Boston
  • 5Department of Psychiatry, New York University Grossman School of Medicine, New York
JAMA Psychiatry. 2023;80(1):13-21. doi:10.1001/jamapsychiatry.2022.3679
Key Points

Question  Is mindfulness-based stress reduction noninferior to escitalopram for the treatment of anxiety disorders?

Findings  In this randomized clinical trial of 276 adults with anxiety disorders, 8-week treatment with mindfulness-based stress reduction was noninferior to escitalopram.

Meaning  In this study, mindfulness-based stress reduction was a well-tolerated treatment option with comparable effectiveness to a first-line medication for patients with anxiety disorders.


Importance  Anxiety disorders are common, highly distressing, and impairing conditions. Effective treatments exist, but many patients do not access or respond to them. Mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR) are popular and can decrease anxiety, but it is unknown how they compare to standard first-line treatments.

Objective  To determine whether MBSR is noninferior to escitalopram, a commonly used first-line psychopharmacological treatment for anxiety disorders.

Design, Setting, and Participants  This randomized clinical trial (Treatments for Anxiety: Meditation and Escitalopram [TAME]) included a noninferiority design with a prespecified noninferiority margin. Patients were recruited between June 2018 and February 2020. The outcome assessments were performed by blinded clinical interviewer at baseline, week 8 end point, and follow-up visits at 12 and 24 weeks. Of 430 individuals assessed for inclusion, 276 adults with a diagnosed anxiety disorder from 3 urban academic medical centers in the US were recruited for the trial, and 208 completed the trial.

Interventions  Participants were 1:1 randomized to 8 weeks of the weekly MBSR course or the antidepressant escitalopram, flexibly dosed from 10 to 20 mg.

Main Outcomes and Measures  The primary outcome measure was anxiety levels as assessed with the Clinical Global Impression of Severity scale (CGI-S), with a predetermined noninferiority margin of −0.495 points.

Results  The primary noninferiority sample consisted of 208 patients (102 in MBSR and 106 in escitalopram), with a mean (SD) age of 33 (13) years; 156 participants (75%) were female; 32 participants (15%) were African American, 41 (20%) were Asian, 18 (9%) were Hispanic/Latino, 122 (59%) were White, and 13 (6%) were of another race or ethnicity (including Native American or Alaska Native, more than one race, or other, consolidated owing to low numbers). Baseline mean (SD) CGI-S score was 4.44 (0.79) for the MBSR group and 4.51 (0.78) for the escitalopram group in the per-protocol sample and 4.49 (0.77) vs 4.54 (0.83), respectively, in the randomized sample. At end point, the mean (SD) CGI-S score was reduced by 1.35 (1.06) for MBSR and 1.43 (1.17) for escitalopram. The difference between groups was −0.07 (0.16; 95% CI, −0.38 to 0.23; P = .65), where the lower bound of the interval fell within the predefined noninferiority margin of −0.495, indicating noninferiority of MBSR compared with escitalopram. Secondary intent-to-treat analyses using imputed data also showed the noninferiority of MBSR compared with escitalopram based on the improvement in CGI-S score. Of patients who started treatment, 10 (8%) dropped out of the escitalopram group and none from the MBSR group due to adverse events. At least 1 study-related adverse event occurred for 110 participants randomized to escitalopram (78.6%) and 21 participants randomized to MBSR (15.4%).

Conclusions and Relevance  The results from this randomized clinical trial comparing a standardized evidence-based mindfulness-based intervention with pharmacotherapy for the treatment of anxiety disorders found that MBSR was noninferior to escitalopram.

Trial Registration  ClinicalTrials.gov Identifier: NCT03522844

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4 Comments for this article
Confounding Condition
Jeoffry Gordon, MD, MPH | retired
Were the study subjects evaluated for child abuse trauma (which results in specific epigenetic, neuroanatomic and hormonal changes) and, if so, were they equally distributed in the medication and mindfulness groups? Some studies show mindfulness is more effective and medication is less effective in psychiatric symptoms generated from the experience of child maltreatment trauma.
Three concerns with the study from an outpatient psychiatrist's perspective
Joseph Arpaia, MD | Private Practice
I am an outpatient psychiatrist also trained in CBT, meditation and EMDR. I have a few issues with the study.

1) I am concerned that the authors did not report the results at 12 weeks and 24 weeks in the abstract. A non-inferiority study at 8 weeks is worthless to me as an outpatient psychiatrist. I find that anxiety symptoms may a robust response to treatment in the short term, but then reassert themselves after a few months.

2) A course of treatment that requires as much time as the MBSR course described in the study
would be out of the question for most of my patients, most of whom are overworked health care professionals who don't have enough time to eat or sleep. Telling people who are that overworked they should spend 45 minutes a day meditating is the "Let them eat cake" of psychotherapy.

3) Why did the authors choose the CGI-S scale which in my opinion is rather non-specific instead of a more specific measure of anxiety.
Health Care Providers
Bonnie Mac Evoy, BA, MD, MPH | Mad River Community Hospital
"... overworked health care professionals who don't have enough time to eat or sleep. Telling people who are that overworked they should spend 45 minutes a day meditating is the "Let them eat cake" of psychotherapy."

Letting people who suffer from anxiety and other health problems believe that it is OK to be unable to find 45 minutes in a day is enabling. Those who cannot find the time in their day to meditate or pursue other self-care activities (good nutrition, exercise, rest) are the very ones who need it most. One can walk and meditate, stop and tune
out for 10 minutes, or even a few minutes of breathing exercises.

Until health care providers push back on the system that expects them to make themselves sick while helping others, the system will use and abuse them. In professions with high risk of suicide, substance abuse, marriage failures and other personal crises, I see counselling as a cry for help requiring substantive interventions and lifestyle changes. When it becomes bad enough that they seek psychological counseling, a pill is going to be part of the problem and like mopping the floor while leaving the sink faucet fully open and spilling over.
Impact of medical comorbidities and age on patient compliance with mindfulness-based interventions
Murli Mishra, M.D. Ph.D. | Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232
This study reported the non-inferiority of mindfulness-based stress reduction techniques compared to first-line pharmacological treatment. This data can impact not only psychiatry but also many other specialties involved in the care of patients with comorbid anxiety. Anxiety is often challenging comorbidity to other medical conditions in elderly patients. Authors have reported the psychiatric comorbidities in publication without any indication of other medical comorbidities. The mean and standard deviation of the age for Hoge EA et study was 33 and 13 respectively. The patient’s noncompliance remains a major challenge in patient care due to varying factors often discussed by clinicians. It will be interesting to see data related to the impact of medical comorbidities on patient compliance with mindfulness-based interventions. The inclusion of higher age groups may further increase the associated challenges due to increased noncompliance often observed in the elderly population who is more likely to have other comorbid conditions. Future research may help us understand the compliance rate with long-term mindfulness practices as opposed to the compliance rate associated with taking pills. A variety of other factors may impact the extrapolation of this study. However, the impact of other medical comorbidities and age will remain a major determinant of the applicability of this data to other medical specialties.