Long-term effects of mindfulness-based cognitive therapy in patients with obsessive-compulsive disorder and residual symptoms after cognitive behavioral therapy: Twelve-month follow-up of a randomized controlled trial
Introduction
Approximately one-third of patients with obsessive-compulsive disorder (OCD) do not respond to cognitive behavioral therapy (CBT) as the first-line intervention (Öst et al., 2015). Furthermore, relapse rates in OCD are high, with more than half of those individuals who show a partial or full symptom remission, subsequently relapse (Eisen et al., 2013). To enhance treatment effects, mindfulness-based interventions might be a possible complementary treatment option. Mindfulness-based interventions aim to teach an open, non-judgmental awareness and acceptance of present-moment experience. Through this, individuals with OCD could learn to accept rather than escape from negative thoughts, which could reduce the need to engage in compulsions (e.g., Fairfax, 2008). In western psychotherapy, mindfulness-based interventions were first implemented in structured group programs such as mindfulness-based stress reduction (MBSR, Kabat-Zinn, 2013) but have also been used in individual therapy settings (Mander et al., 2019; Michalak et al., 2019). Mindfulness-based interventions have been shown to be equivalent to evidence-based therapies for reducing symptoms of depression and anxiety at post-treatment (Goldberg et al., 2018). Similar results were found for a reduction in depressive symptoms at follow-up, but not enough studies had been conducted to assess the long-term effects on symptoms of anxiety (Goldberg et al., 2018). A small number of studies on mindfulness-based interventions in OCD exist and there is preliminary evidence showing that mindfulness-based inventions could be beneficial in OCD (for a review, see Manjula & Sudhir, 2019).
Mindfulness-based cognitive therapy (MBCT) was originally developed as a relapse prevention for recurrent depression and combines mindfulness meditation and elements of CBT (Segal et al., 2013). MBCT has been found to be effective in reducing depression, with the most robust findings related to relapse prevention in depression (e.g., Galante et al., 2013). This positive effect of MBCT remains through to the follow-up period at which MBCT shows similar reductions of depressive symptoms in patients with a current episode of depression compared to active therapies, however, the number of studies is small (Goldberg et al., 2019). With only two previous studies on MBCT in OCD, research in this field is scarce but shows some promising results. Both studies were conducted as an augmentation for CBT and showed a significant reduction in OCD symptoms compared to a waitlist control . However, those studies are limited by methodological problems, such as the lack of an active control group, small sample size and short follow-up intervals of less than three months (Key et al., 2017; Selchen et al., 2018).
Recently, we conducted a randomized controlled trial assessing the effectiveness of MBCT compared to a group receiving psychoeducation in patients with OCD. At post treatment, patients profited more from MBCT compared to the control condition on secondary outcomes, but no differences were found at the 6-month follow-up (Külz et al., 2019). Meta-analyses highlight the importance of longer follow-up periods (Goldberg et al., 2019), and in one previous study MBCT was shown to be superior to the active control condition only at the 12-month follow-up (Bowen et al., 2014). The present study is a 12-month follow-up (FU-12) on the previously published findings of the randomized controlled trial (Külz et al., 2019). As described in the study protocol (Külz et al., 2014) we planned to determine the number of treatment responders, partial responders, and nonresponders as well as the effect of MBCT on OC symptom reduction, and on secondary outcomes such as depressive symptoms and quality of life. We hypothesized that MBCT would show a greater reduction from baseline to 12-month follow-up of OCD symptoms as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; primary outcome) compared to the active control condition. Furthermore, we investigated possible moderators on symptom change. Another exploratory analysis was based on the assumption that an effective MBCT treatment would teach participants to refrain from resisting or controlling thoughts. Thus, participants who learned to adapt a mindful way to deal with their obsessions and compulsions would likely report a lower resistance to obsessions or compulsions (item 4 of the Y-BOCS) or a lower degree of control over obsessive thoughts (item 5 of the Y-BOCS). This would, however, lead to higher scores on items 4 and 5 and higher scores on the Y-BOCS in general. Therefore, it was planned to test the effect of MBCT on the composite score of the first three items of the Y-BOCS (namely, time occupied by obsessive thoughts, interference due to obsessive thoughts, and distress associated with obsessive thoughts).
Section snippets
Study design and interventions
We conducted a bicentric, interviewer-blind, randomized, and actively controlled clinical trial to examine the effectiveness of MBCT for individuals with OCD who had previously not responded to CBT. Our MBCT protocol for OCD relied on the adaptation of a manual for prevention of relapse in patients with major depression (Segal et al., 2013). We compared MBCT to a psychoeducational group program (OCD-EP) to control for unspecific effects of group treatment. Besides psychoeducational elements
Results
T-tests for independent samples revealed that participants who could not be reassessed at FU-12 assessment did not differ from those who were reassessed at FU-12 on either sociodemographic data (age, years of education, gender (χ2-test); ps > .054) or psychopathological baseline data (Y-BOCS total, Y-BOCS obsessions, Y-BOCS compulsions, OCI-R, BDI-II, BSI, WHOQOL-BREF, KIMS-D, OBQ-44, MCQ-30, SCS, DTS; ps > .20). Thus, it can be assumed that the data was missing at random.
The repeated measures
Discussion
This is the first study to evaluate a 12-month follow-up on the effects of MBCT among individuals with OCD who had not responded to CBT. Independent of group allocation, a significant reduction of OC symptoms was demonstrated for the four assessment points with a large effect size, showing that both group programs were effective in reducing OC symptoms over the course of one year post treatment. Furthermore, the significant reduction between FU-6 and FU-12 indicates that treatment effects at
Authors statement
Term Authors Conceptualization Anne Katrin Külz, Steffen Moritz, Nina Rose Methodology Barbara Cludius, Anne Katrin Külz, Sarah Landmann, Steffen Moritz Validation Thomas Heidenreich, Lena Jelinek, Ulrich Voderholzer Formal analysis Barbara Cludius, Johanna Schröder Investigation Barbara Cludius, Birgit Hottenrott, Sarah Landmann Resources Anne Katrin Külz, Steffen Moritz Data Curation Barbara Cludius, Sarah Landmann, Lena Jelinek Writing - Original Draft Barbara Cludius, Sarah Landmann Writing - Review & Editing
Declaration of Competing Interest
None.
Acknowledgments
The authors thank Julia Bierbrodt, Lara Bücker, and Katharina Nitsche for their help with the data collection. This study was supported by grant KU 2754/4-1 and MO 969/15–1 of the German Research Foundation (DFG).
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2022, Journal of Obsessive-Compulsive and Related DisordersCitation Excerpt :The other five studies (Cludius et al., 2020; Hanstede et al., 2008; Külz et al., 2019; Mathur et al., 2021; Rupp et al., 2019) applied mindfulness skills training (e.g., detached mindfulness and mindfulness exercises such as mindful breathing, eating, and walking) as the main intervention component. Eight studies incorporated group-based MBIs supervised by qualified therapists (Cludius et al., 2020; Hanstede et al., 2008; Key et al., 2017; Külz et al., 2019; Madani et al., 2013; Mathur et al., 2021; Rupp et al., 2019; Strauss et al., 2018), one study provided an online MBI with a self-help manual for participants (Cludius et al., 2015), and one study delivered mindfulness meditation practices at home with the support of an EEG-based biofeedback device (Hawley et al., 2021). Across the included studies, the average number of MBIs sessions was 8.20 ± 1.99 (range: 4–12 sessions), and the average session duration was 91.10 ± 40.14 min (range: 40–120 min).
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2021, Journal of Affective DisordersCitation Excerpt :With MBCT, there was a significant improvement in certain belief domains of the OBQ suggesting that the treatment not only reduces illness severity but also changes underlying dysfunctional beliefs. Our finding of decrease in certain dysfunctional beliefs is in line with the recent studies of MBCT (Cludius et al., 2020; Key et al., 2017; Külz et al., 2019, 2014). The studies by Kulz et al. examined the efficacy of MBCT in comparison with psychoeducation in patients who were partial responders or non-responders to CBT (Cludius et al., 2020; Külz et al., 2019, 2014).