Mindfulness-based interventions (MBIs) have emerged as alternative treatments to treat anxiety and stress-related disorders. The aim of this study is to investigate the effectiveness of MBIs if compared to control interventions and cognitive behavioral therapy (CBT) to improve internalizing symptoms in patients with anxiety and stress-related disorders. We performed a systematic review and multilevel meta-analysis of randomized controlled trials. Outcomes were anxiety, stress, and depression rating scales (internalizing symptoms), further classified as pertaining to distress and fear symptom domains. A total of 40 outcomes were retrieved from 10 studies. MBIs were superior to control interventions for internalizing and distress, but not for fear symptoms. CBT was not superior to MBIs for internalizing and distress, but CBT was superior to MBIs for fear symptoms. The majority of the included studies have a high risk of bias and small sample size, and we found evidence of publication bias for some outcomes. Therefore, results should be interpreted cautiously. MBIs seem promising therapeutic options for treating distress symptoms in anxiety disorders; however, more research is needed to recommend MBIs as first-line treatments. MBIs do not seem effective to treat fear symptoms, for which CBT is significantly more effective.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Arch, J. J., Ayers, C. R., Baker, A., Almklov, E., Dean, D. J., & Craske, M. G. (2013). Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders. Behaviour Research and Therapy, 51(4–5), 185–196. https://doi.org/10.1016/j.brat.2013.01.003.
Asmaee Majid, S., Seghatoleslam, T., Homan, H., Akhvast, A., & Habil, H. (2012). Effect of mindfulness based stress management on reduction of generalized anxiety disorder. Iranian Journal of Public Health, 41(10), 24–28.
Azad Marzabadi, E., & Hashemi Zadeh, S. M. (2014). The effectiveness of mindfulness training in improving the quality of life of the war victims with post traumatic stress disorder (PTSD). Iranian Journal of Psychiatry, 9(4), 228–236.
Baxter, A. J., Scott, K. M., Vos, T., & Whiteford, H. A. (2013). Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological Medicine, 43(5), 897–910. https://doi.org/10.1017/S003329171200147X.
Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based stress reduction therapy on mental health of adults with a chronic medical disease: a meta-analysis. Journal of Psychosomatic Research, 68(6), 539–544. https://doi.org/10.1016/j.jpsychores.2009.10.005.
Bystritsky, A. (2006). Treatment-resistant anxiety disorders. Molecular Psychiatry, 11(9), 805–814. https://doi.org/10.1038/sj.mp.4001852.
Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. Journal of Alternative and Complementary Medicine., (5, 5), 593–600. https://doi.org/10.1089/acm.2008.0495.
Clark, L. A., & Watson, D. (2006). Distress and fear disorders: an alternative empirically based taxonomy of the “mood” and “anxiety” disorders. The British Journal of Psychiatry: the Journal of Mental Science, 189, 481–483. https://doi.org/10.1192/bjp.bp.106.03825.
Comer, J. S., Blanco, C., Hasin, D. S., Liu, S. M., Grant, B. F., Turner, J. B., & Olfson, M. (2011). Health-related quality of life across the anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions (NESARC). The Journal of Clinical Psychiatry, 72(1), 43–50. https://doi.org/10.4088/JCP.09m05094blu.
Crane, C., Crane, R. S., Eames, C., Fennell, M. J., Silverton, S., Williams, J. M., & Barnhofer, T. (2014). The effects of amount of home meditation practice in mindfulness based cognitive therapy on hazard of relapse to depression in the Staying Well after Depression Trial. Behaviour Research and Therapy, 63, 17–24. https://doi.org/10.1016/j.brat.2014.08.015.
Cristea, I. A., Huibers, M. J., David, D., Hollon, S. D., Andersson, G., & Cuijpers, P. (2015). The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: a meta-analysis. Clinical Psychology Review, 42, 62–71. https://doi.org/10.1016/j.cpr.2015.08.003.
Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. The Canadian Journal of Psychiatry, 58(7), 376–385. https://doi.org/10.1177/070674371305800702.
Goldin, P., Ziv, M., Jazaieri, H., & Gross, J. J. (2012). Randomized controlled trial of mindfulness-based stress reduction versus aerobic exercise: effects on the self-referential brain network in social anxiety disorder. Frontiers in Human Neuroscience, 6(295). https://doi.org/10.3389/fnhum.2012.00295.
Goldin, P. R., Morrison, A., Jazaieri, H., Brozovich, F., Heimberg, R., & Gross, J. J. (2016). Group CBT versus MBSR for social anxiety disorder: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(5), 427–437. https://doi.org/10.1037/ccp0000092.
Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R., Ballenger, J. C., & Fyer, A. J. (1999). The economic burden of anxiety disorders in the 1990s. The Journal of Clinical Psychiatry, 60(7), 427–435.
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of Psychosomatic Research, 57(1), 35–43. https://doi.org/10.1016/S0022-3999(03)00573-7.
Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. The Journal of Clinical Psychiatry, 69(4), 621–632.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169–183. https://doi.org/10.1037/a0018555.
Hoge, E. A., Bui, E., Marques, L., Metcalf, C. A., Morris, L. K., Robinaugh, D. J., Worthington, J. J., Pollack, M. H., & Simon, N. M. (2013). Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. The Journal of Clinical Psychiatry, 74(8), 786–792. https://doi.org/10.4088/JCP.12m08083.
Huijbers, M. J., Spinhoven, P., Spijker, J., Ruhe, H. G., van Schaik, D. J., van Oppen, P., Nolen, W. A., Ormel, J., Kuyken, W., van der Wilt, G. J., Blom, M. B., Schene, A. H., Donders, A. R., & Speckens, A. E. (2015). Adding mindfulness-based cognitive therapy to maintenance antidepressant medication for prevention of relapse/recurrence in major depressive disorder: randomised controlled trial. Journal of Affective Disorders, 187, 54–61. https://doi.org/10.1016/j.jad.2015.08.023.
Jazaieri, H., Goldin, P. R., Werner, K., Ziv, M., & Gross, J. J. (2012). A randomized trial of MBSR versus aerobic exercise for social anxiety disorder. Journal of Clinical Psychology, 68(7), 715–731. https://doi.org/10.1002/jclp.21863.
Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in Clinical Neuroscience, 17(3), 337–346.
Kagan, J., Snidman, N., Kahn, V., & Towsley, S. (2007). The preservation of two infant temperaments into adolescence. Monographs of the Society for Research in Child Development, 72(2), 1–75, vii; discussion 76-91. https://doi.org/10.1111/j.1540-5834.2007.00436.x.
Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., Van Ameringen, M., Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of Canada/Association Canadienne des troubles anxieux and McGill University, Antony, M. M., Bouchard, S., Brunet, A., Flament, M., Grigoriadis, S., Mendlowitz, S., O’Connor, K., Rabheru, K., Richter, P. M., Robichaud, M., & Walker, J. R. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14(Suppl 1), S1. https://doi.org/10.1186/1471-244X-14-S1-S1.
Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: a review of empirical studies. Clinical Psychology Review, 31(6), 1041–1056. https://doi.org/10.1016/j.cpr.2011.04.006.
Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence and risk factors of lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–626.
Kessler, R. C., Angermeyer, M., Anthony, J. C., DE Graaf, R., Demyttenaere, K., Gasquet, I., DE Girolamo, G., Gluzman, S., Gureje, O., Haro, J. M., Kawakami, N., Karam, A., Levinson, D., Medina Mora, M. E., Oakley Browne, M. A., Posada-Villa, J., Stein, D. J., Adley Tsang, C. H., Aguilar-Gaxiola, S., Alonso, J., Lee, S., Heeringa, S., Pennell, B. E., Berglund, P., Gruber, M. J., Petukhova, M., Chatterji, S., & Ustün, T. B. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 6(3), 168–176.
Kim, Y. W., Lee, S. H., Choi, T. K., Suh, S. Y., Kim, B., Kim, C. M., Cho, S. J., Kim, M. J., Yook, K., Ryu, M., Song, S. K., & Yook, K. H. (2009). Effectiveness of mindfulness-based cognitive therapy as an adjuvant to pharmacotherapy in patients with panic disorder or generalized anxiety disorder. Depression and Anxiety, 26(7), 601–606. https://doi.org/10.1002/da.20552.
Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy, 45, 2518–2526. https://doi.org/10.1016/j.brat.2007.04.011.
Krueger, R. F., & Markon, K. E. (2006). Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology. Annual Review of Clinical Psychology, 2, 111–133. https://doi.org/10.1146/annurev.clinpsy.2.022305.095213.
Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., Lewis, G., Watkins, E., Brejcha, C., Cardy, J., Causley, A., Cowderoy, S., Evans, A., Gradinger, F., Kaur, S., Lanham, P., Morant, N., Richards, J., Shah, P., Sutton, H., Vicary, R., Weaver, A., Wilks, J., Williams, M., Taylor, R. S., & Byford, S. (2015). Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet, 386(9988), 63–73. https://doi.org/10.1016/S0140-6736(14)62222-4.
Lahey, B. B., Applegate, B., Hakes, J. K., Zald, D. H., Hariri, A. R., & Rathouz, P. J. (2012). Is there a general factor of prevalent psychopathology during adulthood? Journal of Abnormal Psychology, 121(4), 971–977. https://doi.org/10.1037/a0028355.
Lumley, T. (2010). Complex surveys: a guide to analysis using R. Hoboken, Wiley.
Martel, M. M., Pan, P. M., Hoffmann, M. S., Gadelha, A., do Rosario, M. C., Mari, J. J., Manfro, G. G., Miguel, E. C., Paus, T., Bressan, R. A., Rohde, L. A., & Salum, G. A. (2017). A general psychopathology factor (P factor) in children: Structural model analysis and external validation through familial risk and child global executive function. Journal of Abnormal Psychology, 126(1), 137–148. https://doi.org/10.1037/abn0000205.
McIndoo, C. C., File, A. A., Preddy, T., Clark, C. G., & Hopko, D. R. (2016). Mindfulness-based therapy and behavioral activation: a randomized controlled trial with depressed college students. Behaviour Research and Therapy, 77, 118–128. https://doi.org/10.1016/j.brat.2015.12.012.
Mendlowicz, M. V., & Stein, M. B. (2000). Quality of life in individuals with anxiety disorders. American Journal of Psychiatry, 157, 669–682. https://doi.org/10.1176/appi.ajp.157.5.669.
Parikh, S. V., Quilty, L. C., Ravitz, P., Rosenbluth, M., Pavlova, B., Grigoriadis, S., Velyvis, V., Kennedy, S. H., Lam, R. W., MacQueen, G. M., Milev, R. V., Ravindran, A. V., Uher, R., & CANMAT Depression Work Group. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 2. Psychological treatments. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 61(9), 524–539. https://doi.org/10.1177/0706743716659418.
Piet, J., Hougaard, E., Hecksher, M. S., & Rosenberg, N. K. (2010). A randomized pilot study of mindfulness-based cognitive therapy and group cognitive-behavioral therapy for young adults with social phobia. Scandinavian Journal of Psychology, 51(5), 403–410. https://doi.org/10.1111/j.1467-9450.2009.00801.x.
Polusny, M. A., Erbes, C. R., Thuras, P., Moran, A., Lamberty, G. J., Collins, R. C., Rodman, J. L., & Lim, K. O. (2015). Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: a randomized clinical trial. JAMA, 314(5), 456–465. https://doi.org/10.1001/jama.2015.8361.
Roshanaei-Moghaddam, B., Pauly, M. C., Atkins, D. C., Baldwin, S. A., Stein, M. B., & Roy-Byrne, P. (2011). Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety? Depression and Anxiety, 28, 560–567. https://doi.org/10.1002/da.20829.
Salum, G. A., Mogg, K., Bradley, B. P., Gadelha, A., Pan, P., Tamanaha, A. C., Moriyama, T., Graeff-Martins, A. S., Jarros, R. B., Polanczyk, G., do Rosário, M. C., Leibenluft, E., Rohde, L. A., Manfro, G. G., & Pine, D. S. (2013). Threat bias in attention orienting: evidence of specificity in a large community-based study. Psychological Medicine, 43(4), 733–745. https://doi.org/10.1017/S0033291712001651.
Schumer, M. C., Lindsay, E. K., & Creswell, J. D. (2018). Brief mindfulness training for negative affectivity: a systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 86(7), 569–583. https://doi.org/10.1037/ccp0000324.
Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., & Levitan, R. D. (2010). Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67(12), 1256–1264. https://doi.org/10.1001/archgenpsychiatry.2010.168.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373–386. https://doi.org/10.1002/jclp.20237.
Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: a meta-analysis. Clinical Psychology Review, 61(1–8). https://doi.org/10.1016/j.cpr.2018.03.002.
Strauss, C., Cavanagh, K., Oliver, A., & Pettman, D. (2014). Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: a meta-analysis of randomised controlled trials. PLoS One, 9(4), e96110. https://doi.org/10.1371/journal.pone.0096110.
Viechtbauer, W. (2017). Morris (2008). The metafor package. A meta-analysis package for R. http://www.metafor-project.org/doku.php/analyses:morris2008 / Accessed 05.01.2017.
Vollestad, J., Sivertsen, B., & Nielsen, G. H. (2011). Mindfulness-based stress reduction for patients with anxiety disorders: evaluation in a randomized controlled trial. Behaviour Research and Therapy, 49(4), 281–288. https://doi.org/10.1016/j.brat.2011.01.007.
Vollestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. British Journal of Clinical Psychology, 51(3), 239–260. https://doi.org/10.1111/j.2044-8260.2011.02024.x.
Williams, J. M., Crane, C., Barnhofer, T., Brennan, K., Duggan, D. S., Fennell, M. J., Hackmann, A., Krusche, A., Muse, K., Von Rohr, I. R., Shah, D., Crane, R. S., Eames, C., Jones, M., Radford, S., Silverton, S., Sun, Y., Weatherley-Jones, E., Whitaker, C. J., Russell, D., & Russell, I. T. (2014). Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial. Journal of Consulting and Clinical Psychology, 82(2), 275–286. https://doi.org/10.1037/a0035036.
Wong, S. Y., Yip, B. H., Mak, W. W., Mercer, S., Cheung, E. Y., Ling, C. Y., Lui, W. W., Tang, W. K., Lo, H. H., Wu, J. C., Lee, T. M., Gao, T., Griffiths, S. M., Chan, P. H., & Ma, H. S. (2016). Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial. British Journal of Clinical Psychology, 209(1), 68–75. https://doi.org/10.1192/bjp.bp.115.166124.
Author Marianna de Abreu Costa designed the study and wrote the study protocol, managed the literature searches, extracted the data, performed the analyses, and wrote the first draft of the manuscript.
Author Gabriela Santos D’Alò de Oliveira helped to design the study, managed the literature searches, extracted the data, revised the manuscript, and contributed to the final version of the manuscript.
Author Tiago Tatton-Ramos participated in the study design, revised the manuscript, and contributed to the final version of the manuscript.
Author Gisele Gus Manfro participated in the study design, revised the manuscript, and contributed to the final version of the manuscript.
Author Giovanni Abrahão Salum participated in the study design, contributed to the study protocol, supervised the data analyses, revised the manuscript, and contributed to the final version of the manuscript.
All authors have approved the final version of the manuscript.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Researches’ scholarships and funding for the research group were funded by Brazilian government agencies (CNPq and FIPE-HCPA).
Conflict of Interest
MAC, GS, GGM, and GAS declare no conflicts of interest. TT is a cofounder of Iniciativa Mindfulness in Brazil.
Not required since all data used in this review comprised information available in the public domain.
Not required since all data used in this review comprised information already available in the public domain and did not involve humans.
Research Involving Human Participants and/or Animals
This study did not involve humans and/or animals.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
About this article
Cite this article
de Abreu Costa, M., D’Alò de Oliveira, G.S., Tatton-Ramos, T. et al. Anxiety and Stress-Related Disorders and Mindfulness-Based Interventions: a Systematic Review and Multilevel Meta-analysis and Meta-Regression of Multiple Outcomes. Mindfulness 10, 996–1005 (2019). https://doi.org/10.1007/s12671-018-1058-1
- Behavior therapy
- Mindfulness, anxiety disorders
- Affective symptom
- Internalizing symptoms