Article

The Effectiveness of Mindfulness-Based Interventions

on Anxiety Disorders. A Systematic Meta-Review
Ascensión Fumero 1, * , Wenceslao Peñate 1 , Cristián Oyanadel 2 and Bárbara Porter 2
1 Departamento de Psicología Clínica, Psicobiología y Metodología, Facultad de Psicología,
Campus de Guajara, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain; [email protected]
2 Facultad de Ciencias Sociales, Universidad de Concepción, 4030000 Concepción, Chile;
[email protected] (C.O.); [email protected] (B.P.)
* Correspondence: [email protected]




Received: 23 June 2020; Accepted: 8 July 2020; Published: 14 July 2020


Abstract: Objective: There has been a growing interest in the study of the effectiveness of
mindfulness-based interventions (MBIs). Many clinical trials and experimental designs have been
implemented, with different samples and diverse MBI procedures. Reviews have shown unclear
results, apart from a tendency to identify low-to-moderate effectiveness. The purpose of this
review is to examine the effectiveness of MBIs on anxiety complaints, analyzing available systematic
reviews and meta-analyses. Method: The literature search was done in MEDLINE (PubMed) and
PsycINFO, from the first available review in 2003 until March 2020. From 82 initial references,
12 reviews were selected. Results: Reviews confirmed a moderate effect size of MBIs in improving
anxiety symptoms. This efficacy was similar to that of well-established therapies for reducing
anxiety symptoms, such as cognitive behavioral therapies. A large effect size was found when
well-developed MBI protocols were applied. Discussion: More refined clinical trials are needed to
establish clear conditions of MBI effectiveness (protocols, samples, psychological mechanisms, etc.).
In addition, considering mindfulness processes, new outcome measures are needed (such as
acceptance, self-awareness, or well-being) to test the incremental value of MBIs.

Keywords: mindfulness; systematic review; meta-analysis; anxiety; effectiveness

1. Introduction
The use of meditation as a therapeutic resource for physical and psychological problems has
enjoyed appreciable growth in recent decades. Mindfulness represents a well-known meditation
procedure in clinical practice. As is known, mindfulness is mainly based on Buddhist mind-body
considerations. According to [1], this includes viewing human suffering as part of how people deal
with some (negative) processes of the mind: human beings increase their suffering and distress when
they focus on negative emotions. Mindfulness tries to teach a new way of relating with negative
feelings through different processes and strategies (observing, describing, acting with awareness,
nonjudging, and nonreacting) based on focusing on the present moment [2].
While the precise “active principle” behind mindfulness efficacy remains unclear, processes
such as self-awareness, focused attention, and emotion regulation are frequently cited as playing a
central role in the functioning of mindfulness [3]. In addition, acceptance processes are frequently
included as the prevalent emotion regulation strategy in mindfulness meditation, as part of a wide
range of mindfulness acceptance-based therapies [4]. Specifically, patients with anxiety disorders
frequently focus on their anxiety symptoms as being representative of their suffering. Mindfulness
practice teaches patients “to attend to a wide range of changing objects of attention while maintaining

Eur. J. Investig. Health Psychol. Educ. 2020, 10, 704–719; doi:10.3390/ejihpe10030052 www.mdpi.com/journal/ejihpe
Eur. J. Investig. Health Psychol. Educ. 2020, 10 705

moment-to-moment awareness (mindfulness), rather than restricting one’s focus to a single object such
as a mantra” (p. 937, [5]).
Although there are several forms for applying mindfulness (e.g., [6]), Mindfulness-based
interventions (MBIs), mindfulness-based programs, mindfulness-based therapies, and mindfulness-
based training are terms used to represent the strategies for applying this therapeutic resource.
These include several procedures, such as mindfulness-based stress reduction (MBSR, [7]),
mindfulness-based cognitive therapy (MBCT, [8]), mindfulness and acceptance-based intervention
(MABI, [9]), and mindful self-compassion (MSC, [10]). It is likely that these protocols have favored the
clinical application of mindfulness and studies of its effectiveness [2]. Therefore, several systematic
reviews and meta-analyses have been carried out.
In general, MBIs have proven to be an effective therapeutic procedure for a variety of psychological
and physical problems, usually with moderate effect sizes, including negative emotional strategies,
such as rumination (e.g., [11]). In addition to being used for anxiety disorders, MBIs have also been
applied to many health problems and disorders, such as depression, social functioning, prosocial
behavior, pain, sleep disturbances, and problems in cancer sufferers [12].
Yet MBI applications have not always been considered effective, nor equally effective. For example,
in Strauss, Cavanagh, Oliver, and Pettman’s review [13] there were significant effects of applying MBI
on anxiety symptom reduction, but these were not sufficient when patients had a diagnosis of anxiety
disorders; in Piet and Hougaard’s review [14], similar results were found for depressive symptoms;
also, in Veehof, Oskam, Schreurs, and Bohlmeijer’s review [15], no significant effects were found in
quality of life in patients with chronic pain. In Roche, Kroska, and Denburg’s review [16], there were not
significant effects for smoking cessation (and a significant but slight effect for weight loss). In Kreplin,
Farias, and Brazil’s review [17], no effects were observed of meditation on some prosocial behaviors
such as aggression or prejudice. In addition, when some significant effects were found (on compassion
and empathy), this was only observed when MBI effects were contrasted against a passive control
group. Interestingly, these authors also found a controversial bias: when meditation teachers/trainers
participated as co-authors of publication, more significant positive effects were found. On the other
hand, no special adverse effects were observed as a consequence of meditation practice and, when these
unwanted effects (such as anxiety/stress, depersonalization, or loss of consciousness/dizziness) were
found, practitioners stated that these symptoms were transitory [18].
These disparities about the efficacy of MBIs can be ascribed to several reasons, most of which are
related to conceptual clarity and methodological refinement. These include the use of different sample
types: patients, subclinical samples, or non-clinical samples (e.g., [19]); differences in patient age
(e.g., [20]); or the study of different meditation practices, with varying numbers of sessions, the absence
of a comparison active control group, and no double-blind design [21]. Notably, the samples used
in clinical trials or experimental research were diverse in their diagnoses; in addition, there were
differences in diagnosis stage, with both acute and recurrent disorders covered (e.g., [22]).
These differences in the conditions led to different conclusions being drawn. This is especially
relevant for anxiety disorders: in literature reviews focusing on different mental disorder studies,
the largest effect size for MBIs was found for anxiety disorders, compared with other mental disorders
(i.e., [23]), moderate effect size, comparable efficacy of other active treatments (i.e., [24]), and inconsistent
results. Even a general moderate effect was found (i.e., [21,25]).
Given these disparities in the literature, the purpose of this review is to carry out a meta-review
on the effectiveness of different MBI applications for anxiety disorders. It includes literature reviews
directly related with MBIs and different anxiety disorders as well as general mental health reviews that
provide specific and separate quantitative data for anxiety disorders.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 706

2. Materials and Methods

2.1. Sources/Literature Research

A systematic literature search was performed in the MEDLINE (PubMed) and PsycINFO electronic
databases. MEDLINE/PubMed is the premier bibliographic database dedicated to health studies in the
behavioral sciences. Furthermore, this research included the main database in the field of psychology
(PsycINFO).
Studies reported in English or Spanish were included, from the year for the first available review
(2003), to March 2020. We did not predefine any dates for the search. The search strategy was
developed for each electronic database using the combination of the following medical subject heading
(MeSH) and free-text terms: anxiety disorders diagnostic ([anxi*] OR [Anxiety disorders] OR [phobi*]
OR [Generalized Anxiety Disorder] OR [GAD] OR [panic] OR [compulsi* Disorder] OR [CD] OR
[social phobia] OR [post-trauma*] OR [PTSD]) AND mindfulness intervention ([mindfulness-based
strategies] OR [mindfulness-based treatments] OR [mindfulness-based interventions] OR [MBI] OR
[mindfulness-based therapies] OR [mindfulness-based approaches] OR [mindfulness-based program]
OR [mindfulness-based stress reduction] OR [MBSR] OR [mindfulness-based cognitive therapy] OR
[MBCT]) AND meta-analysis ([meta-analysis] OR [MA] OR [meta-analytic study] OR [systematic
review] OR [RS] OR [review]).
The search strategies were developed and tested. The references of selected articles were inspected.
Initially, duplicates were removed from the total of identified records. Title and abstracts from the
remaining records were then screened. Later, for assessment of eligibility the full-text articles were
retrieved. Finally, studies fulfilling inclusion criteria were selected. The four authors verified the
retrieval process.

2.2. Selection Criteria

Inclusion criteria: (i) Narrative review, scope studies, systematic reviews (SR), and meta-analytic
studies (MA) examining the pre-post or controlled effects of MBIs for a wide range of psychological
conditions related to anxiety disorders. (ii) Reviews published in peer-reviewed journals. (iii) Reviews
examining nonrandomized and randomized controlled trials, experimental studies, and randomized
clinical trials. (iv) Participants with a diagnosis of anxiety disorders or subclinical samples with higher
levels of anxiety that can be signs of anxiety disorder. (v) Different types of intervention: mindfulness
meditation, mindfulness-based cognitive therapy (MBCT), mindfulness-based stress reduction (MBSR),
other types of MBIs, and mindfulness-based psychotherapy (MBP) interventions. (vi) Reviews selecting
studies with comparison conditions: no intervention, control, waiting list, treatment as usual (TAU),
other treatment group, or other active control groups. (vii) Studies including at least some of the
following outcome measures: improvement in clinical anxiety scales, global anxiety improvement,
anxiety improvement determined by clinician, and improvement in anxiety level specified by trials.

2.3. Exclusion Criteria

Studies were excluded if they (i) did not include at least one mindfulness-based intervention
group; (ii) did not aim to examine treatment effects or reported no clinical outcomes or no measures of
MBI anxiety effectiveness; (iii) were reviews about observational studies, cross-sectional studies or
case-control designs; (iv) were comparisons among meditators or among meditation styles; (v) used
non-mindfulness forms of meditation, such as transcendental meditation; or (vi) were reviews
examining mindfulness as a component of another treatment; and (vii) were published in languages
other than English or Spanish.

2.4. Study Selection and Data Extraction

All the authors assessed the eligibility criteria. The inter-rater reliability was not calculated but
disagreements in the studies inclusion were resolved by consensus. Information was extracted from
Eur. J. Investig. Health Psychol. Educ. 2020, 10 707

each included review that met the eligibility criteria, based on the following: name of the first author;
year of publication; quantity and characteristics of the study (design, randomization); target population;
implemented intervention; comparison group/s; effect size (Hedges’ g), 95% confidence interval,
and p-values for each included study; main results after intervention and, if possible, follow-up.

2.5. Data Analysis and Synthesis

The data from the included reviews are presented descriptively following the structure of Table 1.
The reviews included showed whether a factor was described as having a positive or a negative
influence on the implementation of intervention results. Due to the large variety of factors described and
methods used, no quantitative pooling was performed across the reviews. Moreover, the large majority
of the reviews studied did provide numbers, for example, in the form of effect sizes. Conclusions for the
meta-review were therefore based on the conclusions and results presented in the reviews. The changes
from baseline to post-intervention in anxiety and other continuous outcome measures were compared
between participants who received MBI and those who received control/other interventions.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 708

Table 1. Summary of studies included in the review.

First Author Implemented

Studies Included Target Population Comparison Group Effect Size Main Results
and Year Intervention
Kabat-Zinn et al. [27] examined
patients with generalized anxiety
and panic disorders and found
21 uncontrolled and
significant improvements (also at
controlled studies, but Anxiety clinical
[26] MBSR None d = 0.70 3-month follow-up). Miller,
only two were based sample
Fletcher, and Kabat-Zinn [28]
on anxiety disorder
reported a 3-year follow-up of
the same participants and results
were maintained.
For anxiety disorders, ES
estimates suggest that The uncontrolled pre-post ES
None, TAU, educational
mindfulness-based therapy was estimates were in the moderate
social support with
39 uncontrolled and Anxiety clinical moderately effective for range for reducing anxiety
[29] MBSR or MBCT relaxation, anxiety
controlled studies sample improving anxiety (Hedges’ g = symptoms. MBT in patients with
education program,
0.63; 95% CI = 0.47 to 0.87) from anxiety disorders was associated
waiting list
pre- to post-treatment in the with a large ES.
overall sample
MBIs are associated with robust
and substantial reductions in
Multi-component symptoms of anxiety. No
Individuals with
19 controlled and acceptance-based Between groups Hedges’ g = significant differences emerged
[30] clinical levels of Stand-alone mindfulness
uncontrolled trials interventions −0.83; 95% CI = −1.62 to −0.04 between stand-alone
anxiety
(CBT) mindfulness interventions and
multi-component treatment
packages.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 709

Table 1. Cont.

First Author Implemented

Studies Included Target Population Comparison Group Effect Size Main Results
and Year Intervention
The average degree of anxiety Anxiety obtained significant but
Patients diagnosed
11 randomized decreased compared to TAU unstable results in sensitivity
[31] with anxiety MBCT TAU
controlled trials (Hedges’ g = −0.42; 95% CI = analyses comparing additive
disorders
−0.74 to −0.09) MBCT against usual treatment.
MBT is moderately effective in
pre-post comparisons, in
comparisons with waitlist
Pre-post studies, waiting The SMD was large (10 studies
controls and when compared
Medical conditions list controlled and pre-post) for anxiety studies
209 waiting with other active treatments,
and non-clinical psycho-educational (Hedges’ g = 0.89; 95% CI = 0.71
list-controlled studies including other psychological
[23] population with MBI interventions, supportive to 1.08) and for 4
but only 32 focused treatments. MBT did not differ
elevated initial therapies, relaxation and waitlist-controlled studies
on anxiety from traditional CBT or
anxiety imagery/suppression (Hedges’ g = 0.96 (95% CI = 0.67
behavioral therapies or
technique to 1.24)
pharmacological treatment. MBT
was associated with the largest
mean ES for anxiety.
There was a non-significant
post-MBI between-group
There were no significant
Active control conditions difference in anxiety symptom
12 randomized post-intervention between-group
MBCT, MBSR and (psychoeducation) and severity (Hedges’ g = −0.52; 95%
controlled trials; 9 Full diagnostic benefits of MBIs relative to
[13] person-based inactive control conditions CI = −1.11 to 0.06). MBCT vs.
included a measure of criteria for anxiety inactive control conditions on
cognitive therapy (waiting list, aerobic inactive control (Hedges’ g =
anxiety symptoms anxiety symptom severity nor
exercise) −1.03; 95% CI = −0.40 to −1.66).
was there was an active control.
MBCT vs. active control (Hedges’
g = 0.03; 95% CI = 0.54 to −0.48).
Eur. J. Investig. Health Psychol. Educ. 2020, 10 710

Table 1. Cont.

First Author Implemented

Studies Included Target Population Comparison Group Effect Size Main Results
and Year Intervention
The interventions based on
mindfulness constitute an
effective treatment for GAD, SP,
and PTSD, when used as
adjuncts to pharmacological
It was suggested that
treatment. However, an ES that
psychological interventions
combines the significant
based on mindfulness constitute
differences obtained for each of
8 randomized and Waiting list, TAU, an effective treatment for GAD
Anxiety clinical ACT, MBCT, the disorders is not provided.
[32] non-randomized psychoeducation, CBT, (from d = 0.92 to d = 3.4), SP
sample MBSR For the comparison between
clinical trials aerobic exercises, relaxation (from d = 0.41 to d = 0.78), and
treatments based on mindfulness
PTSD (d = 0.63) when used as
and other treatments for anxiety
adjuncts to pharmacological
(CBT, applied relaxation, and
treatment
aerobic exercise), it is suggested
that the former is not superior to
the latter in terms of efficacy.
Both MBSR and MBCT seem
highly efficient interventions.
ES varied from not effective
(Hedges’ g = 0.23) to large and
Anxiety symptoms positive (Hedges’ g = 1.90). Effect-size estimates suggest that
7 randomized with a wide range The random effect model mindfulness-based CBT is
Pre-post studies, control
[33] controlled trials of physical and MCBT and ACT showed an overall moderate ES moderately effective on anxiety
and active control groups
(RCTs) psychological (Hedges’ g = 0.58; 95% CI = 0.27 symptoms in older adults (g =
conditions to 0.88) of mindfulness-based 0.58)
CBT for anxiety symptoms
among older adults
Based on 11 comparisons, a
significant, small ES was found
ACT, MBCT, for online MBIs on anxiety, with A small but significant ES was
15 RCTs, 11 MBSR, g = 0.22 (95% CI = 0.05 to 0.39, found on anxiety. The online
Anxiety clinical
[34] comparisons on Internet-based Control group p = 0.010) and no outliers. After MBIs are not as effective as
sample
anxiety Mindfulness removal of low-quality studies traditional face-to-face MBIs in
treatment from the analysis, the ES was reducing anxiety.
virtually the same (g = 0.21, 95%
CI = 0.03 to 0.40, p = 0.022).
Eur. J. Investig. Health Psychol. Educ. 2020, 10 711

Table 1. Cont.

First Author Implemented

Studies Included Target Population Comparison Group Effect Size Main Results
and Year Intervention
For anxiety, MBIs were
142 randomized equivalent to the comparison Mindfulness-based interventions
No treatment, specific
clinical trials (18 Anxiety clinical group (d = 0.15 (95% CI = −0.16 were equivalent to the
[21] MBI active control,
based on anxiety sample to 0.46) and were equivalent to comparison group and EBTs for
evidence-based treatment
disorders) EBTs (d = −0.18 (95% CI = −0.41 anxiety
to 0.06)
No statistically or practically
Anxiety clinical Between groups Cohen’s d = significant differences between
[35] 9 randomized trials MBI CBT (active control groups)
sample −0.02; 95% CI = −0.16 to 0.12 mindfulness and cognitive
behavioral intervention
MBIs were superior to control
interventions for internalizing
(SE = 0.26; 95% CI = 0.64 to 0.12;
p = 0.00) and distress (SE = 0.12;
95% CI = 0.7 to 0.21; p = 0.00), MBIs were superior to control
but not for fear symptoms (SE = interventions for internalizing
10 randomized Anxiety clinical 0.22; 95% CI = 0.45 to 0.4; p = and distress, but not for fear
[36] MBCT and MBSR Control conditions, CBT
controlled trials sample 0.90). A significant difference symptoms. CBT was superior to
that favor CBT over MBIs for the MBIs for fear symptoms but not
fear domain symptoms were for internalizing and distress.
found (SE = 0.1; 95% CI = 0.1 to
0.46; p = 0.00). No evidence for
superiority of CBT over MBIs
was found.
Notes: CBT = cognitive behavioral therapy; MBI = mindfulness-based interventions; MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness-based stress reduction;
CBGT = cognitive behavioral group therapy; SMD = standardized mean difference; TAU = treatment as usual; RCT = randomized controlled trial; CI = confidence interval;
NA= not available; ES = effect size; ACT= acceptance and commitment therapy; GAD = generalized anxiety disorder; SP = social phobia; PTSD = posttraumatic stress disorder;
EBT = Evidence-based treatment.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 712

3. Results
We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines [37] to examine reporting in a systematic way.
A total of 82 potentially relevant records were retrieved in the literature search. After screening
all by title and abstract and removing duplicates and studies not subject to peer review, a total of
40 references were identified (Figure 1). Of these, most were excluded either because they did not
report pertinent outcome measures, they did not refer to anxiety disorders, interventions based on the
mindfulness technique were not applied, or not enough results data were provided. Twelve articles
were considered eligible for inclusion through this combined search strategy. The methodological
quality of these reviews was examined using the AMSTAR tool [38]. Table 2 summarizes the responses
to the AMSTAR items. As can be observed, 10 reviews reached the required methodological quality in
more than half of the items, and six of those studies obtained a positive rating in eight or more items.
Only two reviews showed clear methodological insufficiencies.
In general, the reviews formulated a clear research question, searched for studies in appropriate
electronic data sources, presented a comprehensive summary table (with the main data of studies
selected), and, when applicable, used suitable methods to combine results. The more critical aspect has
to do with the absence of a list of excluded studies, followed by the practical exclusion of grey literature.

Figure 1. Study flow chart.

Eur. J. Investig. Health Psychol. Educ. 2020, 10 713

Table 2. Methodological quality of selected review studies, using the AMSTAR tool.

AMSTAR Items
First Author and Year 1 2 3 4 5 6 7 8 9 10 11 Total YES
[26] YES NO YES NO NO YES NO NO A YES NO CNA 4
[29] YES YES YES NO NO YES YES YES YES NO YES 8
[30] YES YES YES NO NO YES NO NO A YES YES CNA 6
[31] YES YES YES NO NO YES NO A NO A YES YES YES 7
[23] YES YES YES NO NO YES YES YES YES YES YES 9
[13] YES CNA YES YES NO YES YES CNA YES YES CNA 7
[32] YES CNA YES NO NO YES NO NO A NA NO YES 4
[33] YES YES YES YES NO YES CNA YES YES YES YES 9
[34] YES YES YES NO NO YES YES YES YES YES CNA 8
[21] YES YES YES YES NO YES YES YES YES NO YES 9
[35] YES CNA YES NO NO YES NO NA YES YES CNA 5
[36] YES YES YES NO NO YES YES YES YES YES YES 9
Notes: AMSTAR items: 1. Was an “a priori” design provided?; 2. Was there duplicate study selection and data extraction?; 3. Was a comprehensive literature search performed?; 4.
Was the status of publication (i.e., grey literature) used as an inclusion criterion?; 5. Was a list of studies (included and excluded) provided?; 6. Were the characteristics of the included
studies provided?; 7. Was the scientific quality of the included studies assessed and documented?; 8. Was the scientific quality of the included studies used appropriately in formulating
conclusions?; 9. Were the methods used to combine the findings of studies appropriate?; 10. Was the likelihood of publication bias assessed?; 11. Were potential conflicts of interest
included? C N A = Cannot answer; N A = Not applicable.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 714

3.1. Descriptive Characteristics

As shown in Table 1 the 12 reviews (ordered by publication date) comprise a total of 196 studies.
When considered by category of design, eight reviews and meta-analyses (RSs/Mas) restricted selection
to randomized controlled trials. The rest included non-randomized trials or pre-post experimental
designs. Few reviews offered data about the methodological quality of the studies selected. In those
that did, the quality ranged from moderate to low [21,29]. In the best review, 40% of studies were
considered to be of high quality [39]. Studies included mainly samples with anxiety disorders, but also
included anxiety symptoms within a wide range of psychological conditions [23,33].
The type of meditation reviewed was especially diverse. More than half of the reviews included
studies with comparable protocols MBIs (MBSR, MBCT). In addition, comparison groups varied.
MBIs were frequently compared with an inactive control group or TAU group. When studies included
active control groups, those groups usually did not receive a protocolled alternative treatment.
Five RSs/MAs included studies where MBIs were compared with well-established cognitive behavioral
therapy (CBT) treatments [21,23,30,33,35].
Finally, referring to outcome measures, self-reported levels of anxiety were usually included
(via inventories and scales). Few RSs/MAs selected studies had other dependent measures, such as
attrition rates, adherence to treatment, or well-being/quality of life [13,33]. The contrasts for those
outcome measures were provided in Hedges’ g or Cohen’s d.

3.2. MBI Effectiveness

A total of 9 of the 12 (75%) reviews indicated a positive effect of MBIs, comparing pre-post
intervention anxiety scores and compared with a control group. In three SRs/MAs, with MBI vs.
comparison group, the effect size did not reach a significant level, or the results were equivalent
between MBI group and comparison group. This equivalence was especially true when the comparison
group included some CBT intervention [13,21,32,37].
For RSs/MAs with positive results for mindfulness, the weighted mean effect size was standardized
mean difference (SMD) = 0.57 (95% CI = 0.22–0.89); for those with negative results, SMD = −0.27
(95% CI: −0.52–0.02). Participants receiving MBI improved their anxiety levels, with a medium
effect size.
For the studies with positive results for mindfulness in comparison to control or other intervention
groups, the range of effect size was large for 20% of studies [23,30], moderate for 50% [26,29,32,33,39],
and small for 30% [31,34,36]. Non-favorable comparisons were found by Strauss, Cavanagh, Oliver,
and Pettman [13], with non-significant post-MBI between-group differences in anxiety symptom
severity; by Singh and Gorey [35], with no significant differences observed between the mindfulness
and CBT groups on anxiety levels; and by Goldberg et al. [21], where mindfulness-based interventions
were equivalent both to the comparison group and to evidence-based treatment. These different
types of effectiveness are not associated with the methodological characteristics of these reviews;
in each effectiveness category (positive, equal to other treatment, non-favorable), reviews with different
methodological qualities are mixed.
Reviews considering samples with a clinical diagnosis of anxiety disorders showed a positive
effect of MBI, but with several nuances. Baer [26], Hoffmann et al. [29] and Kishita et al. [33] obtained
a moderate effect size. Galante et al. [31] found significant but unstable positive effects (depending
on the studies selected). In Goldberg et al. [21], Strauss et al. [13], and Hodann-Caudevilla and
Serrano-Pintado [32], MBI effectiveness was not superior to CBT intervention.
MBI significantly reduced anxiety levels, with moderate effect sizes. Reviews about the application
of standard protocols (MBSR, MBCT) found more diverse effect sizes, and several RSs/MAs did not
find significant differences between MBSR/MBCT and other active treatments in reducing anxiety
levels [13,23].
Eur. J. Investig. Health Psychol. Educ. 2020, 10 715

Finally, the reviews verified the frequent absence of follow-up in the studies selected.
When follow-up was included, the results pointed to the maintenance of moderate effectiveness
of MBI [23], with moderate (median 15%) attrition rates [13].

4. Discussion
The therapeutic effectiveness of MBIs has been assessed through multiple clinical trials (randomized
and non-randomized) and experimental designs. In general, data support its efficacy, frequently with
a moderate effect size, but there still are inconclusive results. This is especially true when MBIs are
used to improve anxiety levels. An appreciable number of systematic reviews and meta-analyses have
been published to determine MBIs efficacy on anxiety problems. The outcomes of these reviews do not
reach clear conclusions. In that sense, this paper has analyzed those literature reviews, trying to find a
synthesis of the major results of MBIs on anxiety-related problems, and searching for conditions where
MBIs show a better efficacy.
Twelve reviews were selected. In general, there is a clear tendency to consider MBIs as an effective
resource for reducing anxiety problems; MBIs improve anxiety levels, as seen when comparing pre-post
intervention scores or comparing mindfulness with an inactive control or TAU group. This effectiveness
tends to reach moderate effect sizes. In addition, these effects—when data were available—persist in
follow-up, with moderate drop-out rates. This finding was verified in several randomized controlled
trials (i.e., [31,33,36]). Furthermore, when MBIs are compared with well-established therapies for anxiety
disorders (especially CBTs), there are no differences observed between them (i.e., [35]). However, when
MBIs are provided via the Internet, their efficacy is less positive [34]. Apparently, the methodological
quality of these reviews is not associated with a specific MBI effectiveness level but with the absence of
a list of excluded studies and the exclusion of grey literature.
Nevertheless, the literature reviews included in this review also show some inconsistencies.
As Hoffmann et al. [29] point out, MBIs are useful for reducing anxiety levels when participants have a
high level of anxiety, but MBIs do not have enough power when they are applied to individuals with a
diagnosis of anxiety disorders. Another insufficiency is related with the effect size obtained by applying
MBIs. Few studies found large effect sizes. Several CBTs obtained similar (or better) results. Therefore,
according to incremental validity, what reasons make MBIs eligible? According to data provided by
Khoury et al. [23], large effect sizes are obtained when standard protocols of mindfulness are applied
(such as MBSR or MBCT). However, if we examine the kind of meditation used, there are still several
experimental studies using different meditation procedures [39]; these procedures are frequently
not comparable, nor are the duration, number, or content of sessions the same (e.g., transcendental
meditation, yoga, or tai-chi). This represents a relevant methodological problem.
If we consider the type of participants, a generalized positive effect of MBIs is observed that is
not related to the nature of the sample. Anxiety reduction can be detected in samples with medical
or mental problems and in non-clinical samples [23]. Yet, as mentioned above, improvements are
insufficient to generate a clinical change when participants have a diagnosis of anxiety disorder [29].
This last result can hide a methodological problem: frequently reviews include samples with anxiety
disorders, as a general label (where different anxiety disorders were incorporated); but it is possible
MBIs can differentially affect anxiety, depending on the type of anxiety disorder (panic, generalized,
etc.). Unfortunately, with the available data provided from reviews, we cannot answer this hypothesis.
Although, this data can represent an opportunity for an epistemological change to how MBIs are
evaluated: the main outcome measure used to assess MBI effectiveness (and other therapies) is
symptom reduction. This is obvious, because this measure is directly related with human suffering.
Yet mindfulness meditation also implies other changes, according to its conceptual foundations.
These changes are related to the use of acceptance as a strategy for emotion regulation, self-awareness,
or well-being. In this sense, measuring these variables can be an opportunity to highlight the
incremental value of applying MBIs. Secondary outcome measures, such as relapse prevention,
adherence to treatment, or attrition rates [13,33] can participate in this incremental value.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 716

Finally, little attention is paid to relevant variables, such as type of therapist, cost-effectiveness, or
the reasons that make MBIs work. As Kreplin et al. [17] critically pointed out, the type of therapists and
their training (as teachers, psychologists, or other) can play a relevant role in the effectiveness of MBIs.
What is more, Carsley, Khoury, and Heath [40] found a differential effectiveness that was dependent on
the type of trainer/therapist. Singh and Gorey [35] pointed out that MBIs are cost-effective, but that
more precise studies are needed, with an objective methodology (and comparing MBIs with other
effective therapies such as CBT). As mentioned in the introduction, there are several supposed active
principles explaining why mindfulness works [3]. As Norton [41] states, there are enough data
to hypothesize how some strategies can be more effective, but there are no trials testing different
mindfulness strategies.
According to these data, we think future reviews could deal with more methodologically refined
studies. When a bias analysis was done, the methodological quality was found to be medium or
low. As Goldberg et al. [21] pointed out, despite the interest in improving MBI design, relevant
methodological problems remain. In this sense, reviews of well-designed randomized clinical trials,
with comparable MBI protocols (preferably MBSR or MBCT), active control groups (especially groups
receiving CBTs), follow-up, and with clinical samples, can offer more relevant and clear results about
the effectiveness of MBIs. Analysis of outcome measures could provide both statistical and clinical
efficacy. Furthermore, analysis of outcome measures indirectly related with treatment efficacy (attrition
rates, adherence) could modify MBI effectiveness criteria. Finally, studies about the “active principle”
of mindfulness are sorely lacking, and if there are different mechanisms according to MBI protocol
and type of treated problem. These mechanisms could also observe the role of mindfulness as a
protective/preventive resource for mental and biomedical problems [42,43].
This meta-review has several limitations. The selected RSs/MAs were directly related to anxiety
problems. Anxiety disorders can include different anxiety processes (panic disorders, generalized
anxiety disorders, etc.), and it is possible to think MBIs can differentially affect those processes
involved. Studies included in several reviews were with subclinical samples or included samples with
different physical and mental complaints, and so it is possible that these interventions have differential
effectiveness, depending on the target problem. Studies were obtained from peer-reviewed journals,
but there may be many unpublished or online trials not collected in this review. Not all the studies
extracted share a similar MBI procedure, and it can be questionable whether those procedures were
really comparable. In spite of the number of search literature databases established, the present search
was done in two major databases; thus, the results could be constrained because of the remaining
databases excluded.

5. Conclusions
Several general conclusions can be drawn: (i) The RSs and MAs reviewed confirm the existence
of well-designed randomized controlled trials (RCTs) testing the effectiveness of different MBIs.
(ii) These reviews point out the significant efficacy of MBIs in improving anxiety symptoms.
However, this efficacy is similar to that obtained with traditional CBT. (iii) Large effectiveness
was obtained when well-developed MBI protocols were applied, and with non-clinical anxiety samples.
(iv) Existing data support high adherence to MBIs. Finally, (v) incremental gains of MBI application
could be found in variables closer to mindfulness processes, such as self-awareness, acceptance,
and well-being.

Author Contributions: A.F. and W.P. designed the study and coordinated the data collection. All the authors
contributed to the data analyses and manuscript preparation. All authors have approved the final manuscript.
All authors have read and agreed to the published version of the manuscript.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial,
or not-for-profit sectors.
Conflicts of Interest: The authors declare no conflicts of interest. This research does not contain any studies with
human participants or animals performed by any of the authors. Informed consent was not required.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 717

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