Pseftogianni, F., Panagioti, M., Birtwell, K., & Angelakis, I. (2023). Mindfulness interventions for obsessive–compulsive and related disorders: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 233-243. https://doi.org/10.1037/cps0000132

Key Points

This meta-analysis examined the effectiveness of mindfulness interventions (MIs), including mindfulness-based interventions (MBIs) and mindfulness-informed therapies (MITs), for obsessive-compulsive and related disorders (OCRDs).
Results of the meta-analysis provide initial evidence for medium to large benefits of mindfulness interventions in reducing overall symptom severity across OCRDs. However, benefits were limited for common symptoms like obsessions and depression.
Treatment gains were not sustained at follow-up, suggesting mindfulness may not solve the problem of OCD relapse.
This highlights the need to continue optimizing mindfulness protocols by incorporating strategies that target these symptoms directly, rather than just overall severity.
Studies from lower-income countries using acceptance and commitment therapy (ACT) contributed larger reductions in OCD symptoms and depression.
Tolin (2023) argues there is an overlap between ERP and acceptance/mindfulness approaches in OCD treatment. Both emphasize decreasing compulsions and exposure exercises, though they differ in emphasis. ERP emphasizes exposure more, while acceptance focuses on letting go of control of thoughts.

Rationale

Obsessive-compulsive and related disorders (OCRDs) are serious mental health conditions involving obsessions and compulsions that can significantly impair functioning (American Psychiatric Association, 2013).

First-line treatments like exposure therapy have limitations, including high relapse rates and complexity in practice (Gillihan et al., 2012; Olatunji et al., 2013).

Mindfulness interventions emphasize present-moment awareness with an attitude of non-judgment (Kabat-Zinn, 2004). They have shown promise for improving both physical and mental health across disorders (de Vibe et al., 2017; Demarzo et al., 2015; Goldberg et al., 2022).

The mindfulness skill of non-reactivity, or allowing thoughts and feelings to come and go without reacting, may be particularly helpful for managing intrusive thoughts in OCD (Hawley et al., 2017; Landmann et al., 2019).

Despite high anxiety and depression comorbidity in OCRDs (Fineberg et al., 2013), no systematic review has evaluated mindfulness interventions for the full range of OCRDs and common symptoms like obsessions and depression.

Establishing an evidence base for these interventions can inform treatment guidelines and help address the limitations of first-line approaches.

Method

This systematic review and meta-analysis followed PRISMA guidelines (Page et al., 2021). Five databases were searched for RCTs on mindfulness interventions for OCRDs.
Eligibility criteria: 8+ years old with OCRD diagnosis, mindfulness interventions compared to any control groups, validated OCRD outcome measures.
26 RCTs with 1281 participants were included. Meta-analyses calculated pooled standardized mean differences (SMDs) in OCRD severity between mindfulness and control groups.
Subgroup analyses examined individual symptoms and depression. Meta-regressions explored the influence of study characteristics on effectiveness.

Sample

1281 participants aged 13.9-46.2 years (mean 31.2), 34.5% male.
88.5% had formal OCRD diagnosis, 11.5% by self-report. 15 studies focused on OCD, 6 on BDD, 5 on TTM. No studies on hoarding or skin picking.
Most from high income countries. Race/ethnicity data lacking.

Results

Mindfulness interventions had medium effects on OCD at post-treatment (SMD = -0.62) and small effects at follow-up (SMD = -0.48). High heterogeneity (I2=90%) but minimal publication bias.
Medium effects were found for body dysmorphic disorder (BDD) at post-treatment (SMD = -0.65) and follow-up (SMD = -0.74). No heterogeneity or publication bias.
Large effects for trichotillomania (TTM) at post-treatment (SMD = -1.52), low heterogeneity. No follow-up data.
Small reductions in OCD obsessions at post-treatment (SMD = -0.32) but not follow-up. Small decreases in OCD depression at post-treatment only.
Meta-regressions: larger OCD reductions in lower-income countries and with ACT. MBCT trended towards greater OCD and depression reductions

Implications

First-line treatments for OCRDs have limitations – mindfulness may help address these.
Considering the high psychiatric burden of OCRDs, mindfulness interventions represent a promising treatment approach both on their own and as an adjunct to established therapies.
Mindfulness was less effective for obsessions and comorbid depression, highlighting areas for refinement.
Lower-income countries showed greater benefits, suggesting potential for cost-effective treatment.
Tailoring protocols like ACT and MBCT that directly target OCD and depression appears promising.
Lack of long-term follow-up data for most OCRDs indicates need for studies on sustainability.

Future Research

More research is vital to strengthen the evidence base so these interventions can effectively help address the significant patient need.

Further research needed across OCRD diagnoses, symptoms, demographics, and adverse effects.
Further high quality RCTs with larger samples are needed to establish stronger evidence across the range of OCRDs, patient demographics, and sustainable outcomes.
Research is lacking on hoarding disorder, skin picking disorder, long-term outcomes for TTM, and adverse effects of MIs. More high-quality RCTs on OCRDs are needed.
It is unclear if acceptance/mindfulness represent “intentional” treatments where the key components drive effectiveness, or “inadvertent” treatments where incidental exposure exercises are active. More dismantling research is needed.
Potential risks of mindfulness for OCD patients have not been thoroughly examined.

Strengths & Limitations

The study had many methodological strengths, including:

Rigorous PRISMA guidelines followed, with low risk of bias overall
Controlled for exposure techniques to isolate unique effects of mindfulness
Assessed multiple OCRDs and common symptoms like obsessions and depression
Examined influence of methodological factors through meta-regressions
Used statistical methods to assess heterogeneity and publication bias

However, this study was limited in a few ways:

High heterogeneity in analyses, reflecting the diverse nature of OCRDs
Small samples for BDD and TTM limit generalizability of findings
Meta-regressions likely underpowered due to few studies
Groupings for exposure techniques may be imperfect without study protocols
Most studies lacked data on race/ethnicity and adverse effects
It’s unknown if effects are due to mindfulness specifically versus other treatment components.
It’s unclear which specific OCD patients mindfulness works best for (e.g. severity level, subtype).

Conclusion

This is the first comprehensive meta-analysis demonstrating medium to large benefits of MIs for overall symptom severity across multiple OCRDs – OCD, BDD, and TTM. The effects were sustained without exposure techniques, highlighting the unique therapeutic benefits of mindfulness.

Mindfulness allows practicing non-reactivity to intrusive thoughts, a key skill for managing obsessions in OCD. However, the meta-analysis found only transient benefits for obsessions and no effects on comorbid depression.

This indicates the need to optimize protocols by incorporating strategies that directly target these symptoms, rather than just overall severity. Exploring evidence-based MIs like MBCT and ACT appears fruitful, as they showed greater OCD reductions.

The lack of follow-up data for TTM and absence of trials for other OCRDs underscores the need for more research across disorders.

Considering the high psychiatric comorbidity with OCRDs, using mindfulness as an adjunct or stand-alone treatment offers promise but requires more rigorous study.

References

Primary Paper

Pseftogianni, F., Panagioti, M., Birtwell, K., & Angelakis, I. (2023). Mindfulness interventions for obsessive–compulsive and related disorders: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 233-243. https://doi.org/10.1037/cps0000132

Other References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

de Vibe, M., Bjørndal, A., Fattah, S., Dyrdal, G. M., Halland, E., & Tanner-Smith, E. E. (2017). Mindfulness-based stress reduction (MBSR) for improving health, quality of life and social functioning in adults: A systematic review and meta-analysis. Campbell Systematic Reviews, 13(1), 1-264. https://doi.org/10.4073/csr.2017.11

Demarzo, M. M. P., Montero-Marin, J., Cuijpers, P., Zabaleta-del-Olmo, E., Mahtani, K. R., Vellinga, A., Vicens, C., Lopez-del-Hoyo, Y., & García-Campayo, J. (2015). The efficacy of mindfulness-based interventions in primary care: A meta-analytic review. Annals of Family Medicine, 13(6), 573–582. https://doi.org/10.1370/afm.1863

Fineberg, N. A., Haddad, P. M., Carpenter, L., Gannon, B., Sharpe, R., Young, A. H., Joyce, E., Rowe, J., Wellsted, D., Nutt, D. J., & Sahakian, B. J. (2013). The size, burden and cost of disorders of the brain in the UK. Journal of Psychopharmacology, 27(9), 761–770. https://doi.org/10.1177/0269881113495118

Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common pitfalls in exposure and response prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 251–257. https://doi.org/10.1016/j.jocrd.2012.05.002

Goldberg, S. B., Riordan, K. M., Sun, S., & Davidson, R. J. (2022). The empirical status of mindfulness-based interventions: A systematic review of 44 meta-analyses of randomized controlled trials. Perspectives on Psychological Science, 17(1), 108–130. https://doi.org/10.1177/1745691620968771

Hawley, L. L., Rogojanski, J., Vorstenbosch, V., Quilty, L. C., Laposa, J. M., & Rector, N. A. (2017). The structure, correlates, and treatment related changes of mindfulness facets across the anxiety disorders and obsessive compulsive disorder. Journal of Anxiety Disorders, 49, 65–75. https://doi.org/10.1016/j.janxdis.2017.03.003

Kabat-Zinn, J. (2004). Wherever you go, there you are: Mindfulness meditation for everyday life. Piatkus Books.

Landmann, C., Tuschen-Caffier, B., Moritz, B., Külz, S., & K, A. (2019). Mindfulness predicts insight in obsessive–compulsive disorder over and above OC symptoms: An experience-sampling study. Behaviour Research and Therapy, 121, Article 103449. https://doi.org/10.1016/j.brat.2019.103449

Olatunji, B., Davis, M., Powers, M., & Smits, J. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33–41. https://doi.org/10.1016/j.jpsychires.2012.08.020

Page, M., McKenzie, J., Bossuyt, P., Boutron, I., Hoffmann, T., Mulrow, C., Shamseer, L., Tetzlaff, J., Akl, E., Brennan, S., Chou, R., Glanville, J., Grimshaw, J., Hróbjartsson, A., Lalu, M., Li, T., Loder, E., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Journal of Clinical Epidemiology, 134, 178–189. https://doi.org/10.1016/j.jclinepi.2021.03.001

Tolin, D. F. (2023. Mindfulness and acceptance for OCD: New direction or more of the same? Clinical Psychology: Science and Practice, 23(3), 248-250. https://doi.org/10.1037/cps0000142

Mindfulness Interventions for OCD: A Systematic Review and Meta-Analysis