Mindfulness-based stress reduction equivalent to escitalopram for anxiety disorders

21st November 2022

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

The use of mindfulness-based stress reduction (MBSR) techniques decreases anxiety levels to a similar extent as treatment with 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. Consequently, for 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.

Citation
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.

Cannabidiol solution reduces anxiety and improves cognition

10th November 2022

A full spectrum cannabidiol solution significantly reduced anxiety levels and improved several measures of cognition in a recent small study

Cannabidiol (CBD) given as a full-spectrum (i.e. containing all the components in the plant) solution, significantly reduced anxiety levels but also appeared to improve scores on several cognitive-related tests according to the results of a small, open-label study by US researchers.

A 2013 systematic review estimated that globally, anxiety disorders affect 7.3% of the population but can be as high as 10.4% in Euro/Anglo cultures. Whilst there are several effective anxiolytic therapies available, only about 60% of patients respond to those treatments to any significant degree and many have residual symptoms or remain treatment refractory.

Cannabidiol is the most abundant non-psychoactive component of cannabis and has received growing attention due to its anxiolytic and antidepressant properties, representing a promising new agent in the treatment of anxiety and mood disorders. For example, CBD has been found to be effective in patients with generalised social anxiety disorder although to date, only one randomised trial has been undertaken. In this trial, teenagers with social anxiety disorder, received either cannabis oil containing 300 mg of CBD or placebo every day for 4 weeks and saw significant reductions in anxiety.

Although cognitive functioning has rarely been examined in CBD studies, some evidence from studies of those using medical marijuana have found improvements in the multi-source interference test (MSIT), which is a measure of executive function and cognitive control. This finding is at variance to other evidence that suggests chronic, heavy recreational of marijuana use is related to cognitive decrements.

While previous research has examined the anxiolytic action of CBD, this is usually with a highly purified version. In the present study, the US researchers wondered about the anxiolytic effect of a full-spectrum product. The researchers speculated that CBD in its natural form would not only improve anxiety but might also help other related outcomes such as mood, sleep and quality of life.

Moreover, given the suggestion that use of medical marijuana appeared to improve cognition, this too was examined as a secondary outcome. Anxiety was assessing using the Beck Anxiety Inventory (BAI) and for which values > 16 represent at least moderate anxiety.

However, several other anxiety related measures were also included. Participants were required to be either cannabis naive or abstinent from regular use. The cannabidiol extract was homogenised into a solution and given as a 1 ml dose (containing 9.97 mg/ml of CBD) sublingually three times a day. Cognitive assessments included a battery of tests to assess executive function and memory.

cannabidiol and improvement in anxiety

A total of 14 participants with a mean age of 41.36 years (21.4% male) were enrolled. The mean BAI score was 20.29 and this reduced by 79.9% to a mean of 16.21 (p < 0.001) at week 4. In addition, there were significant reductions in all of the other anxiety measures after 4 weeks of treatment. Moreover, self-reported measures of mood, sleep and quality of life were also all significantly improved compared to baseline. Furthermore, the product was well tolerated with no serious adverse events noted.

In terms of cognition, there were also significant improvements in several of the measures assessed, in particular the MSIT which was significantly reduced compared to baseline (p < 0.006).

The authors concluded that the data supported both the efficacy and tolerability of a high cannabidiol product for anxiety and suggested that future clinical studies would focus on the cognitive impact of the formulation.

Citation
Dahlgren MK et al. Clinical and cognitive improvement following full-spectrum, high-cannabidiol treatment for anxiety: open-label data from a two-stage, phase 2 clinical trial. Commun Med 2 2022.