Mindfulness as an Alternative to the Antidepressant Medication Escitalopram for Anxiety Disorder

Standard treatments prescribed for patients who are diagnosed with an anxiety disorder include antianxiety drugs, psychotherapy or a combination of both.[1] However, patients often experience adverse events with medications or have difficulties accessing psychotherapy.

A clinical trial published in January 2023 in Journal of the American Medical Association (JAMA) Psychiatry[2] examined whether a mindfulness intervention[3] provided comparable symptom relief to escitalopram (LEXAPRO), a commonly prescribed antidepressant, for patients diagnosed with an anxiety disorder. Unlike psychotherapy, mindfulness can be taught in community settings and practiced at home.

Although anxiety disorders are relatively common, they are often undiagnosed. However, in September 2022, the U.S. Preventive Services Task Force — a volunteer panel of experts in disease prevention and evidence-based medicine working independently of the drug and medical-device industries — published a draft recommendation that proposes screening for anxiety in adults 65 years of age or younger who are not showing typical symptoms of anxiety.[4] Over time, this recommendation (which has not been finalized as of mid-June 2023) may lead to more patients seeking treatment after receiving an anxiety diagnosis.

Which interventions were compared in the JAMA Psychiatry study?

Previous clinical trials have shown that several interventions based on the concept of mindfulness — being aware of one’s feelings and emotions without interpreting or judging them — can help patients to reduce stress and anxiety.[5],[6] The new study focused on a specific eight-week program called mindfulness-based stress reduction. As part of this program, participants learned several forms of mindfulness meditations, including yoga, walking meditation, body scanning and breath awareness, during weekly classes, one all-day class and daily meditation exercises at home.[7]

Mindfulness-based stress reduction was compared with escitalopram, a selective serotonin reuptake inhibitor (SSRI) that is approved for the treatment of generalized anxiety disorder as well as major depressive disorder.[8] Public Citizen’s Health Research Group has designated this drug as Limited Use[9] because, like all SSRIs, it has a black-box warning due to the increased risk of suicidal thoughts and behaviors in children and young adults. Additionally, drugs in this class have been associated with a number of adverse events, including seizures, abnormal bleeding, sexual dysfunction and a rare but life-threatening condition called serotonin syndrome (which is characterized by agitation, confusion, hallucinations, rapid heartbeat, high blood pressure, high fever, shivering, sweating, nausea, vomiting, diarrhea and muscle rigidity).[10] SSRIs also can cause withdrawal symptoms, such as dizziness, nausea and headaches, especially when discontinued abruptly.

The results of the new study

For the study, 208 patients, aged 18 to 75 years, with an anxiety disorder (including generalized anxiety disorder, social anxiety disorder, panic disorder or agoraphobia [fear of particular places]) were randomly assigned to either complete the mindfulness training or to take escitalopram. The patients’ severity of anxiety before and after the study was assessed on a seven-point scale.[11]

After eight weeks, the symptom reduction in subjects who completed the mindfulness course (1.35) and those in the escitalopram group (1.43) was comparable. The study also found that in both groups, symptoms continued to improve at similar rates at week 12 and week 24.[12]

Although the reduction of symptom severity was comparable between the groups, among patients who took the SSRI, 79% experienced at least one adverse event, such as sleep disturbance, nausea, fatigue, headaches, abnormal dreaming, decreased libido or anxiety, and 8% discontinued their treatment due to adverse events. In the mindfulness group, however, only 15% experienced adverse events, mainly increased levels of anxiety, which did not lead to any study discontinuations.[13]

After eight weeks, more patients taking the SSRI continued with their treatment compared with those in the mindfulness group. For example, at 24 weeks about half of the patients in the SSRI group (52%) were still taking their medication, whereas only 28% in the mindfulness group continued doing daily meditation.[14] Based on these findings, the study’s first author acknowledged that “although mindfulness meditation works, not everyone is willing to invest the time and effort to successfully complete all of the necessary [mindfulness] sessions and do regular home practice.”[15]

Additionally, subjects in this study were predominantly female (75%) and relatively young (33 years on average), which makes it difficult to generalize these findings to other patient groups diagnosed with anxiety disorder. It is also important to note that because the mindfulness techniques were taught by qualified instructors in person, the results of this study may not apply to mindfulness trainings available online or through apps.[16]

What You Can Do

If you have been diagnosed with an anxiety disorder, talk to your health care professional to see whether non-pharmacological treatment options, such as psychotherapy or mindfulness-based interventions, are a good option for you.

Do not discontinue escitalopram without consulting your health care professional first. If you are planning to discontinue this drug, do so gradually by reducing the dosage under medical supervision to minimize withdrawal symptoms. Seek immediate treatment if you develop any of the severe adverse events associated with SSRIs described in this article.
 

References

[1] Craske, M. Generalized anxiety disorder in adults: Cognitive behavioral therapy and other psychotherapies. UpToDate. Updated July 27, 2021.

[2] Hoge EA, Bui E, Mete M, et al. Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: a randomized clinical trial. JAMA psychiatry. 2023;80(1):13-21

[3] NEJM Journal Watch. Mindfulness meditation for anxiety disorders: Good alternative to medication? November 22, 2022. https://www.jwatch.org/na55541/2022/11/22/mindfulness-meditation-anxiety-disorders-good-alternative. Accessed May 3, 2023.

[4] US Preventive Services Task Force. Draft recommendation statement. Anxiety in adults: screening. September 20, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/index.php/draft-recommendation/anxiety-adults-screening. Accessed May 3, 2023.

[5] Haller H, Breilmann P, Schröter M, et al. A systematic review and meta-analysis of acceptance-and mindfulness-based interventions for DSM-5 anxiety disorders. Sci Rep. 2021;11(1):20385

[6] Mayo Clinic. Mindfulness exercises. October 11, 2022. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356. Accessed on May 4, 2023.

[7] Santorelli SF, Kabat-Zinn J, Blacker M, et al. Mindfulness-based stress reduction (MBSR) authorized curriculum guide. Center for Mindfulness in Medicine, Health Care, and Society (CFM). University of Massachusetts Medical School. May 17, 2017.

[8] Allergan: escitalopram oxalate (LEXAPRO). September 2021. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=13bb8267-1cab-43e5-acae-55a4d957630a&type=display. Accessed May 4, 2023.

[9] Drug profile: escitalopram. Worst Pills, Best Pills. https://www.worstpills.org/monographs/view/53. Accessed May 5, 2023.

[10] SSRIs can have dangerous interactions with other drugs. Worst Pills, Best Pills News. January 2008. https://www.worstpills.org/newsletters/view/571. Accessed May 5, 2023.

[11] Hoge EA, Bui E, Mete M, et al. Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: a randomized clinical trial. JAMA psychiatry. 2023;80(1):13-21.

[12] Ibid.

[13] Ibid.

[14] Ibid.

[15] Georgetown University Medical Center. Press release. Mindfulness-Based Stress Reduction is as Effective as an Antidepressant Drug for Treating Anxiety Disorders. November 9, 2022. https://gumc.georgetown.edu/news-release/mindfulness-based-stress-reduction-is-as-effective-as-an-antidepressant-drug-for-treating-anxiety-disorders/#. Accessed May 4, 2023.

[16] Hoge EA, Bui E, Mete M, et al. Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: a randomized clinical trial. JAMA psychiatry. 2023;80(1):13-21.