Effectiveness of a meditation-based stress management program as an adjunct to pharmacotherapy in patients with anxiety disorder

Journal of Psychosomatic Res

Effectiveness of a meditation-based stress management program as an

adjunct to pharmacotherapy in patients with anxiety disorder

Sang Hyuk Leea, Seung Chan Ahnb, Yu Jin Leea, Tae Kyu Choia,4,

Ki Hwan Yooka, Shin Young Suha

aDepartment of Psychiatry, Pochon CHA University College of Medicine, Seongnam, South KoreabKorea Institute of Brain Science, Seoul, South Korea

Received 13 June 2006

Abstract

Objective: The objective of this study was to examine the

effectiveness of a meditation-based stress management program in

patients with anxiety disorder. Methods: Patients with anxiety

disorder were randomly assigned to an 8-week clinical trial of

either a meditation-based stress management program or an anxiety

disorder education program. The Hamilton Anxiety Rating Scale

(HAM-A), the Hamilton Depression Rating Scale (HAM-D), the

State–Trait Anxiety Inventory (STAI), the Beck Depression

Inventory, and the Symptom Checklist-90—Revised (SCL-90-R)

were used to measure outcome at 0, 2, 4, and 8 weeks of the

program. Results: Compared to the education group, the medi-

tation-based stress management group showed significant improve-

ment in scores on all anxiety scales (HAM-A, P=.00; STAI state,

P=.00; STAI trait, P=.00; anxiety subscale of SCL-90-R, P=.00)

0022-3999/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jpsychores.2006.09.009

4 Corresponding author. Department of Psychiatry, Pochon CHA

University College of Medicine, Bundang CHA Hospital, 351 Yatap-Dong,

Bundang-Gu, Seongnam 463-712, South Korea. Tel.: +82 31 780 5864;

fax: +82 31 780 5874.

E-mail address: [email protected] (T.K. Choi).

and in the SCL-90-R hostility subscale (P=.01). Findings on

depression measures were inconsistent, with no significant

improvement shown by subjects in the meditation-based stress

management group compared to those in the education group. The

meditation-based stress management group did not show signifi-

cant improvement in somatization, obsessive–compulsive symp-

toms, and interpersonal sensitivity scores, or in the SCL-90-R

phobic anxiety subscale compared to the education group.

Conclusions: A meditation-based stress management program

can be effective in relieving anxiety symptoms in patients with

anxiety disorder. However, well-designed, randomized, and con-

trolled trials are needed to scientifically prove the worth of this

intervention prior to treatment.

D 2007 Elsevier Inc. All rights reserved.

Keywords: Anxiety disorder; Stress management; Meditation

Introduction

Meditation includes techniques such as listening to

breathing, repeating a mantra, detaching from thought

processes, focusing attention, and bringing about a state of

self-awareness and inner calmness [1]. In Asia, many forms

of meditation have been developed among Taoists, Bud-

dhists, and traditional Chinese medicine practitioners

throughout history [2]. Meditation has been recently

classified as a technique that induces a set of integrated

physiological changes, termed relaxation response [3], and

is now an accepted and effective complementary treatment

for many psychosomatic disorders, such as chronic pain,

fibromyalgia, cancer, epilepsy, and psoriasis [4–8].

Meditation affects the endocrine system by inducing

a progressive decrease in serum thyroid-stimulating hor-

mone, growth hormone, and prolactin levels [9], and

also acts on the immune system to increase the number of

CD3+ lymphocytes and the antibody response to influenza

vaccine [10,11].

Group sessions of meditation-based stress management

can be effective in teaching people how to take better care of

earch 62 (2007) 189–195

S.H. Lee et al. / Journal of Psychosomatic Research 62 (2007) 189–195190

themselves, live healthier lives, and adapt more effectively

to stress. Of a variety of possible meditation programs, the

mindfulness-based stress reduction (MBSR) program of

Kabat-Zinn [12] is a well-defined, systematic, and patient-

centered approach that uses relatively intensive training in

mindfulness meditation as the core of the program.

Anxiety disorders, such as panic disorder and generalized

anxiety disorder, are chronic and recurrent [13]. Patients with

anxiety disorder are usually prescribed anxiolytics, unless

contraindicated. However, a combination of pharmacother-

apy and other kinds of treatment, such as cognitive therapy

and cognitive–behavioral therapy, should be considered

for these patients to maximize their chance of adapting

successfully to social and occupational environments.

Miller et al. [14] and Angst and Vollrath [15] showed that

the MBSR program could effectively reduce symptoms of

anxiety and panic, and could help to maintain these

reductions in patients with generalized anxiety disorder,

panic disorder, or panic disorder with agoraphobia. MBSR

may provide a good candidate program for patients with

anxiety disorder who do not want pharmaceutical medica-

tion, are pregnant, or want additional treatment. However,

this study was limited by the noninclusion of either a

randomly selected comparison group to test for placebo

effects or a control group to test for concomitant medication

effects [14,15]. Therefore, a carefully controlled trial should

be implemented before this kind of stress management

program is applied to patients with anxiety disorder. We have

previously assessed the effectiveness of a newly developed

meditation-based stress management program, which uses

meditation techniques that are widely practiced among

Koreans to improve health, in a preliminary trial on a group

of pregnant women [16]. The meditation in this program was

not the same as that used in the MBSR regime, although the

programs have mindfulness meditation in common. We

therefore aimed here to scientifically demonstrate the

effectiveness of our group meditation program for stress

management in patients with anxiety disorder.

Methods

Subjects

The study involved 46 patients with anxiety disorder.

Subjects were recruited, through advertisement, among

patients who were on treatment on an inpatient or an

outpatient basis at the Department of Psychiatry, Pochon

CHA University College of Medicine from March 2003 to

August 2003. Subjects were between 20 and 60 years of age

and fulfilled the Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition (DSM-IV) criteria for

generalized anxiety disorder or panic disorder with or

without agoraphobia, as diagnosed by two psychiatrists

using the Structured Clinical Interview for DSM-IV Axis I

disorders [17,18]. In all subjects, symptoms were not

relieved after more than 6 months of pharmacotherapy.

Written informed consent was obtained after a full

description of the study had been presented to the sub-

jects. Prior to the study, the subjects were treated with

the antidepressant paroxetine (20 mg/day), sertraline

(50–100 mg/day), or fluvoxamine (50–100 mg/day) and

with the anxiolytic alprazolam (0.125–0.5 mg/day). Psy-

chiatrists confirmed that acute symptoms in the patients had

stabilized and had remained unchanged for the past

2 months. The medications and dosages were not altered

during the study. Exclusion criteria included any history of

substance abuse or dependency, other psychiatric comor-

bidities, significant medical problems (such as diabetes

mellitus, hypertension, tuberculosis, hepatitis, or preg-

nancy), and involvement in litigation or compensation.

Assessment

Subjects were randomly assigned to either the meditation

program or the education program. Subjects were contacted

on the day before the program started to encourage

participation. Three subjects in the meditation group and

two subjects in the education group dropped out during

the study; thus, data from 21 meditation group subjects and

20 education group subjects were used for the final analysis.

Subjects in the meditation group underwent weekly sessions

of meditation treatment for 8 weeks, while the education

group subjects received weekly sessions of general infor-

mation on anxiety disorder. Both groups were assessed at

baseline (0 week) and at 2, 4, and 8 weeks by self-report

measures such as the Beck Depression Inventory (BDI), the

State–Trait Anxiety Inventory (STAI), and the Symptom

Checklist-90—Revised (SCL-90-R), as well as by a subject-

blinded psychiatrist using a clinician-rated scale such as the

Hamilton Depression Rating Scale (HAM-D) or the

Hamilton Anxiety Rating Scale (HAM-A).

Meditation program

A psychiatrist and two meditation specialists with 5 years

of education and training experience conducted the pro-

gram. The meditation program consisted of a training

program that can be performed by anxious patients, together

with the psychiatrist’s complementary instruction on stress

management in anxiety disorder (see Appendix A). The

training program comprised medication, exercise, stretch-

ing, muscle buildup and relaxation, and hypnotic sugges-

tion, with the goal of including it in everyday life through

steady practice. At the end of each session, homework and

an audio CD were given to participants.

Education program

The education program consisted of a presentation from

the psychiatrist and education about the biological aspects of

anxiety disorders, lasting for 1 h, once a week. The education

Table 1

Sociodemographic characteristics of patients with anxiety disorder:

the meditation-based stress management group versus the education

control group

Meditation

group

(n=24)

Education

group

(n=22) v2 or t df P

Age (years)

(meanFS.D.)

38.6F7.4 38.1F9.7 t=0.2 44 .83

Duration of illness

(months)

(meanFS.D.)

12.7F8.0 9.4F4.4 t=-1.3 44 .19

Education (years)

(meanFS.D.)

13.0F2.3 13.5F2.4 t=-0.7 44 .50

Income ($10

per month)

(meanFS.D.)

277.0F59.8 270.4F84.7 t=0.3 44 .75

Sex [n (%)]

Male 15 (63) 15 (68) v2=0.2 1 .68

Female 9 (37) 7 (32)

Religion declared

[n (%)]

15 (63) 15 (68) v2=1.2 1 .27

Employed [n (%)] 17 (70) 16 (72) v2=0.2 1 .48

Married [n (%)] 15 (63) 15 (68) v2=2.3 1 .89

S.D.=standard deviation; t=Student’s t test; v2=chi-square test.

S.H. Lee et al. / Journal of Psychosomatic Research 62 (2007) 189–195 191

curriculum was as follows: bWhat is anxiety disorder (panic

or generalized anxiety disorder)?Q on Weeks 1 and 2;

bsymptoms and respiratory physiology of anxiety disorderQon Weeks 3 and 4, bbiology, anatomy, and pharmacotherapy

of anxiety disorderQ on Weeks 5–7; and bsharing and

discussionQ on Week 8. Stress management techniques and

behavior therapy for anxiety disorder were not included.

Outcome measures

HAM-A

The HAM-A, which was developed by Hamilton [19], is

a semistructured interview comprising 14 items that assess

the severity of anxiety symptoms. The scale consists of two

factors (general psychological anxiety symptoms and

cognitive symptoms) and is rated on a 5-point scale, with

5 being the worst.

STAI

The STAI, developed by Speilberger et al. [20], assesses

state–anxiety and trait–anxiety in a more simplified and

objective self-rated scale. The STAI consists of state–

anxiety (X1 type) and trait–anxiety (X2 type) questions

(20 items each). In this study, we used the STAI as

standardized by Kim and Shin [21].

HAM-D

The HAM-D is a clinician-rated scale that was developed

by Hamilton [22] in 1960 and is one of the most widely

used scales for the assessment of depression. The scale

assesses the psychopathology and the psychology associated

with depressive symptoms and emphasizes somatic symp-

toms. Of 21 items, the first 17 items assess the severity of

depression, and 4 additional items provide information on

other symptoms that need special treatment. Higher scores

indicate more severe depression.

BDI

TheBDI is a self-rated scale that was developed byBeck et

al. [23] to assess the severity of depression. Twenty-one items

are rated on a 3-point scale, with the total score obtained from

the sum of all items. Lee et al. [24] assessed the validity and

the reliability of the version of the scale used here.

SCL-90-R

The standardized SCL-90-R was administered to assess

the severity of psychopathology. The original scale, which

was developed by Derogatis [25], was standardized to the

version of Kim et al. [26] and could be conveniently rated

on an outpatient basis. The scale assesses various symp-

toms, thereby facilitating the detection of psychopathology.

Data analysis

Group differences in religion and occupation were

analyzed using chi-square test, and group differences in

age, duration of pregnancy, education level, income, and

baseline variables were analyzed using independent t tests.

After the 8-week programs, the blast observation carried

forwardQ method was used for intent-to-treat analysis. The

effects of both programs were analyzed using repeated-

measures analysis of variance, whereby two factors were

considered to contrast the performance of both groups.

These factors were: Time main effect (which indicated

whether changes on an outcome variable occurred as a

function of time irrespective of the treatment received) and

Time�Treatment interaction (which indicated whether

subjects in one treatment group changed more than their

counterparts in the other group over time). SPSS/PC Version

11.5 was used for statistical analysis.

Results

Sociodemographic characteristics

There were no significant differences between groups in

sociodemographic characteristics such as age, gender,

education level, marital status, occupation, religion, and

income (Table 1). The baseline scores for each scale were

also not significantly different between the two groups.

Comparison of anxiety scale scores between the meditation

group and the education group

Table 2 summarizes the effects of the two 8-week

programs on anxiety scores. Statistically significant

decreases in anxiety scores over time were revealed for

HAM-A (F=24, df=3,42, P=.00), STAI-1 (F=9, df=3,42,

Table 2

Scores on anxiety scales over time of patients with anxiety disorder: the

meditation-based stress management program group versus the education

control group

Baseline 2 weeks 4 weeks 8 weeks

HAM-Aa (meanFS.D.)

Meditation group 16.6F1.3 12.2F1.3 10.1F1.1 8.5F0.9

Education group 15.9F5.6 16.0F5.2 14.6F5.7 14.9F5.0

STAI-1a (meanFS.D.)



STAI-2a (meanFS.D.)



SCL-90-R anxiety subscalea (meanFS.D.)



a Significant difference in the rate or in the magnitude of changes

between the meditation-based stress management group and the education

control group.


P=.00), STAI-2 (F=13, df=3,42, P=.00), and the SCL-90-R

anxiety subscale (F =7, df =3,42, P=.00). Compared

to subjects in the education group, those in the medi-

tation group showed greater improvement in anxiety

scores. Differences between the two groups remained signif-

icant even after the Time�Treatment interaction was

considered. Fig. 1 shows changes in major anxiety scores

over time.

Fig. 1. Anxiety and depression scales showing significant differences in the r

management group and the education control group.

Comparison of depression scale scores between the

meditation group and the education group

The results listed in Table 3 show that the 8-week

programs both induced statistically significant decreases in

the depression scale scores over time: HAM-D (F=15,

df =3,42, P=.00), BDI (F =8, df =3,42, P=.00), and

SCL-90-R depression subscale (F=6, df=3,42, P=.00).

Comparative changes in depression scores between the

two groups showed different results for different scales.

After the Time�Treatment interactions were considered, the

meditation group showed a significant improvement in

HAM-D scores (F=4, df=3,42, P=.01), but there were no

significant differences between groups in BDI (F=2,

df=3,42, PN.05) or the SCL-90-R depression subscale

(F=2, df=3,42, PN.05). Fig. 1 shows changes in HAM-D

scores over time.

Comparison of SCL-90-R subscale scores between the

meditation group and the education group

Table 4 lists the effects of the 8-week programs on

SCL-90-R subscale scores, excluding the anxiety and

depression subscales.

Both groups showed statistically significant decreases

over time for the somatization subscale (F=5, df=3,42,

P=.00), obsessive–compulsive subscale (F=8, df=3,42,

P=.00), interpersonal sensitivity subscale (F=8, df=3,42,

ate or in the magnitude of changes between the meditation-based stress

Table 3

Scores on depression scales over time for patients with anxiety disorder: the

meditation-based stress management program group versus the education

control group

Baseline 2 weeks 4 weeks 8 weeks

HAM-Aa (meanFS.D.)



BDIb (meanFS.D.)



SCL-90-R depression subscaleb (meanFS.D.)



a Significant difference in the rate or in the magnitude of changes


control group.b No significant difference in the rate or in the magnitude of changes


control group.

Table 4

Scores on SCL-90-R subscales over time for patients with anxiety disorder:

the meditation-based stress management program group versus the


P=.00), phobic anxiety subscale (F=6, df=3,42, P=.00),

and hostility subscale (F=4, df=3,42, P=.01). According to

these results, after consideration of the Time�Treatment

interaction, subjects in the meditation group showed more

improvement in hostility scores (F=3, df=3,42, P=.04),

but there were no significant differences in other subscales

such as the somatization, obsessive–compulsive, interper-

sonal sensitivity, and phobic anxiety subscales. Scores for

paranoid ideation and psychoticism showed no significant

change over time, and there were no significant differences

between the two groups.
education control group
SCL-90-R subscales Baseline 2 weeks 4 weeks 8 weeks

Somatizationa (meanFS.D.)



Obsessive–compulsivea (meanFS.D.)



Interpersonal sensitivitya (meanFS.D.)



Hostilityb (meanFS.D.)



Phobic anxietya (meanFS.D.)



Paranoid ideationa (meanFS.D.)



Psychoticisma (meanFS.D.)



a No significant difference in the rate or in the magnitude of changes


control group.b Significant difference in the rate or in the magnitude of changes

between the meditation-based stress management group and the educa-

tion group.

Discussion

The purpose of this study was to determine whether a

stress management program based on meditation—an

Oriental mind–body intervention—is more beneficial than

educational sessions for patients with anxiety disorders. The

findings revealed significant decreases in anxiety scale

scores for patients with anxiety disorders undergoing the

meditation-based program compared to patients with anxi-

ety disorders undergoing the education program. These

results are consistent with previous studies suggesting that

meditation can relieve anxiety in patients with anxiety

disorders, and they raise the possibility that stress manage-

ment programs based on meditation could be applied as an

adjunct to pharmacotherapy.

In this study, meditation, compared to education,

appeared to induce significant improvements in anxiety

scale and hostility subscale scores, although the other

variables assessed did not show similar results. Depression

scores showed different results with different scales.

According to HAM-D, the meditation group showed

significant improvement, but the BDI and SCL-90-R

depression subscales showed no significant differences

between the two groups. This suggested that subjectively

judged depressive symptoms showed no improvement,

while those judged objectively responded favorably.

Patients might therefore still be suffering from subjective

symptoms of depression, regardless of contradictory objec-

tive findings. This particular finding is inconsistent with a

previous study that was performed without a control group

[13], which argued that meditation significantly improved

both HAM-D and BDI scores in patients with anxiety

disorders. We can therefore infer the following in our

findings. First, there is a possibility that depressive

symptom scores do not reveal significant decreases when

compared to a control group. Second, the meditation

program of this study might differ significantly from that

used by Kabat-Zinn et al. [13]. Third, because our program

was conducted for only 8 weeks, the effects on depression

may not have reached significance compared to the control

group. Fourth, the number of study participants was fairly

low, possibly resulting in contradictory results. However,

considering that the MBSR program of Kabat-Zinn was

quite similar to our program in that they both included

exercises such as stretching, relaxation, and suggestion, and

that both programs were run for 8 weeks, we conclude that

the first assumption is the most likely.

The meditation group in this study showed SCL-90-R

hostility scores that were significantly lower than those of


the education group. This result is consistent with the earlier

findings of Muskatel et al. [27] in their study of hostility and

meditation. Hostility is a characteristic of type A behavior

and, considering the close association of this behavior with

coronary artery disease [28], this finding should be of

significant clinical importance in psychosomatic medicine.

Even though the SCL-90-R subscale scores for the

somatization, phobic anxiety, obsessive–compulsive, and

interpersonal sensitivity subscales decreased significantly

over time, the scores for the two groups were not

significantly different. It should be noted that phobic anxiety

is a particularly important aspect of anxiety disorders such

as panic disorder.

Meditation has both cognitive and cognitive–behavioral

aspects, and many aspects of meditation mirror cognitive–

behavioral therapy, including focusing on sensation and

thoughts instead of focusing on catastrophic thinking,

turning a stressful situation into motive to change behavior,

and practicing homework. In this study, most of the patients

with panic disorder also had agoraphobia, and since the

meditation group showed no significant improvement in

phobic symptoms compared to the control group, we can

assume that the cognitive approach of the meditation

program adopted here was not effective enough.

From this finding, we can infer the following assump-

tions. First, unlike cognitive therapy that focuses on

thoughts, particularly on distorted thinking, meditation

teaches subjects to leave thoughts as they are, thus not

reducing phobic symptoms. Second, the patients might not

have experienced true serenity. Third, although the patients

reported that they trained themselves as instructed, they

might not have worked enough to integrate meditation into

their daily lives, thus not having enough effect on phobias.

Finally, the duration of the program (8 weeks) and

the number of training sessions (60 min weekly) might

have been insufficient to produce a beneficial effect on

this aspect.

The changes in SCL-90-R subscale (paranoid ideation

and psychoticism) scores over time were not significant, and

changes over time for scale scores were not significantly

different between two groups. This suggested that the

meditation program used would not be effective in anxiety

disorders with paranoid or psychotic symptoms. There are

reports of meditation actually causing psychotic symptoms,

and meditation is not recommended in anxiety cases with

psychotic symptoms [29].

This study had the following limitations. First, the

administered medication might have affected the results.

However, carrying out an experimental study with little

verification, free of pharmacotherapy, would be subject to

ethical controversy, and discontinuation of the medications

of patients who are stabilized by such medications is

problematic. For these reasons, subjects were limited to

patients with stabilized symptoms. However, delayed effects

of the medication cannot be ruled out. Second, the control

group underwent an educational program. A true control

group for the meditation program, which would accurately

control for placebo effects, would have been a mimic or a

sham program. Finally, there was no follow-up study to

assess the long-term effects of the interventions. We

observed maintenance of effects in some of the subjects,

but objective data collection was not possible.

Conclusions

This study suggests that in regard to the reduction of

anxiety symptoms and hostility in patients with anxiety

disorders, meditation-based stress management programs

produce results better than those of education-based stress

management programs. However, our findings need to be

confirmed in larger study groups and without some of the

abovedescribed limitations for meditation to be applicable in

the clinical management of these patients.

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First

session

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Education: philosophy, beliefs,

and importance of meditation

Stimulation of lower abdomen (Danjeon area)

Movement of lower abdomen

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Appendix A.

Documents

Effectiveness of a meditation-based stress management program as an adjunct to pharmacotherapy in patients with anxiety disorder