Received: 24 January 2019 Revised: 8 October 2019 Accepted: 31 October 2019

DOI: 10.1111/eip.12902

BRIEF REPORT

Efficacy of a brief mindfulness intervention upon anxiety

in early psychosis patients

Alycia F. Ernst | Dale D'Mello

Department of Psychiatry, Michigan State
University, East Lansing, Michigan
Correspondence
Alycia F. Ernst, Department of Psychiatry,
Michigan State University, General Psychiatry
Residency, East Fee Hall, 965 Fee Road, Suite
A233, East Lansing, MI.
Email: alycia.ernst@hc.msu.edu
Abstract
Aim: To examine the efficacy of a brief mindfulness intervention in reducing anxiety
in early psychosis patients, and to determine whether symptom burden mitigates
therapeutic response.
Methods: Our study included patients who had experienced an initial episode of psy-
chosis, with less than 30 months of antipsychotic exposure. First, the prescriber com-
pleted the COMPASS Clinician Rating Form (measuring symptom burden), and
patients completed the POMS questionnaire (measuring anxiety). A 3-minute mind-
fulness exercise was administered, and patients again completed the POMS scale.
The differences between the pre- and postintervention anxiety scores were analysed
using a paired t test.
Results: A total of 20 subjects participated. The mean Anxiety Subscale of the POMS
scores decreased from 4.6 to 1.7. The change was statistically significant, and not
influenced by symptom burden.
Conclusions: A brief mindfulness exercise, conducted in a routine office visit, pro-
duced a significant reduction in state anxiety for early psychosis patients, regardless
of symptom burden.

KEYWORDS
anxiety, meditation, mindfulness, office visit, psychosis

1 | I N T RO D UC T I O N anxiety symptoms may affect the severity of psychotic symptoms,

There is increasing recognition that patients experiencing first-episode
psychosis (FEP) may struggle not only with significant disease symp-
toms, but also with a burdensome awareness of their diagnosis. The
disease can affect their lives by changing social and occupational
goals, and grappling with the realities of their diagnosis can lead to
depression, anxiety, and low self-esteem (Sönmez et al., 2014). Many
patients may go on to develop posttraumatic stress symptoms follow-
ing a first psychotic episode, related to both the traumatic experience
of symptoms and to the often distressing experience of forced hospi-
talization and treatment (Rodrigues & Anderson, 2017). Unsurpris-
ingly, anxiety severity can be significant in FEP. Several existing
studies focus primarily on the social dynamics of anxiety in FEP, or on
the PTS/PTSD symptoms that develop following the episode. There is
growing interest, however, in better understanding how generalized
and ultimately affect clinical outcome.
One study—which examined 201 FEP patients divided into remit-
ted and unremitted groups at 6 months—sought to assess association
between anxiety severity and disease remission. The groups did not
significantly differ at baseline on either the Hamilton Anxiety Rating
Scale or the Positive and Negative Syndrome Scale, but at 6 months,
were significantly different on both anxiety rating scores. The authors
determined that anxiety severity in FEP appears to be linked to poor
short-term outcome (Montreuil, Malla, Joober, Bélanger, & Lepage,
2013). Another study (a systematic review focused on psychosis)
noted an association between anxiety and the resultant severity of
delusions and hallucinations, advising anxiety as a target focus for
therapeutic intervention (Hartley, Barrowclough, & Haddock, 2013).
Nonpharmacologic methods of addressing affective symptoms in
FEP are garnering increased attention. In studies of the NAVIGATE

Early Intervention in Psychiatry. 2020;14:503–506. wileyonlinelibrary.com/journal/eip © 2019 John Wiley & Sons Australia, Ltd 503
504
model, researchers have demonstrated that FEP patients show
improved clinical outcomes when treated with a multidisciplinary,
team-based approach (Kane et al., 2016). Studies have highlighted the
utility of CBT targeting self-esteem, depression (Sönmez et al., 2014),
and anxiety (Sönmez et al., 2014; Welfare-Wilson & Newman, 2013)
in FEP patients. Other work has linked aspects of mindfulness to
improved outcomes in depression and anxiety following an episode of
psychosis (White et al., 2012).
Mindfulness meditation has widely recognized benefit in treating
symptoms of anxiety and depression. Mindfulness interventions may
benefit psychosis patients via easing distress associated with psy-
chotic symptoms, promoting illness acceptance, fostering a sense of
agency, and facilitating disengagement from the illness experience
(Abba, Chadwick, & Stevenson, 2008; Chadwick, 2014). Although
meditations may need to be modified slightly to be tolerable for psy-
chosis patients (eg, with shorter periods of practice, frequent verbal
guidance, and specific reference to psychotic symptoms as transient
sensations like others), mindfulness has been shown to be safe and
therapeutic for people with psychosis (Chadwick, 2014).
In a qualitative study investigating a mindfulness-based interven-
tion (MIB) in FEP, participants reported subjective improvement in
sense of control of their situation and emotions, improved ability to
relate to others, and better understanding of themselves (Ashcroft,
Barrow, Lee, & Mackinnon, 2011). Some small pre-post studies of
MIB in FEP patients have demonstrated benefits to depression (Tong
et al., 2015) and anxiety (Khoury, Lecomte, Comtois, & Nicole, 2013;
Samson & Mallindine, 2014), as well as emotional regulation, self-care,
and somatic concerns (Khoury et al., 2013). A recent pilot study inves-
tigating a youth-focused group mindfulness-based intervention for
early psychosis patients found benefits to depression and fatigue
(Macdougall et al., 2018).
Most previous studies of MBIs in FEP patients have tested inter-
ventions conducted in group settings. There are benefits to this
approach, including combatting a sense of isolation and engendering
empathy for others (Ashcroft et al., 2011). While perhaps ideal, atten-
dance at classes outside of regularly scheduled appointments may
pose a practical obstacle for some patients. More investigation is
warranted to examine the role of brief, in-office mindfulness-based
interventions targeting anxiety reduction in FEP patients.
2 | METHODS
This study was conducted at ETCH: Early Treatment and Cognitive
Health, a behavioural health clinic in East Lansing, Michigan, utilizing
the “NAVIGATE” early intervention model for early psychosis treat-
ment (including individual resiliency training, family education and
support, supported education and employment, and medication man-
agement). Eligibility at the clinic includes age of 15-30 and the pres-
ence of psychotic symptoms for 18 months or less at the time of
treatment initiation. To recruit for this study, all NAVIGATE patients
at ETCH were invited to participate in a one-time mindfulness exer-
cise in the context of a routinely scheduled psychiatric visit. A total of
ERNST AND D'MELLO
20 patients consented to participate, all of whom had experienced an
initial episode of psychosis, and each of whom had less than
30 months of total antipsychotic exposure.
At the beginning of each session, the treating psychiatrist com-
pleted the COMPASS Clinician Rating Form (Appendix S1), a standard
procedure for each psychiatric visit. The COMPASS form is derived
from the Positive and Negative Symptoms Scale, and measures symp-
tom burden on 12 items, ranging from depression and anxiety to hal-
lucinations and apathy (Robinson et al., 2014). Meanwhile, patients
completed the POMS questionnaire (Appendix S2), which contains
eight mood descriptors for anxiety. Next, a 3-minute recorded “Body
and Sound” mindfulness meditation—available at no cost at the UCLA
Mindful Awareness Research Center website—was administered
(Winston, 2011). The psychiatrist administering this meditation had
no formalized training in mindfulness techniques, although the clini-
cian whose recording was utilized (Diana Winston) is the director of
mindfulness education at UCLA's Mindful Awareness Research Center
and has extensive experience in the teaching and practice of mindful-
ness meditation. At the conclusion of the meditation, patients were
again asked to complete the POMS scale to identify any change in
symptoms.
This was a nonrandomized, pre-post intervention study. The dif-
ferences between the pre- and postintervention anxiety scores
(as measured by the change in POMS score) were analysed statisti-
cally using a paired t test (MYSTAT software). A Pearson correlation
coefficient test was run to evaluate any correlation between pre-
existing symptom burden (as measured by the COMPASS Form) and
anxiety reduction.
Approval for the study was obtained from the Michigan State Uni-
versity Institutional Review Board, and patients were individually con-
sented prior to the intervention.
3 | RESULTS
A total of Twenty subjects participated in the study. As seen in
Figure 1, the mean anxiety subscale of the POMS scores decreased
from 4.6 preintervention to 1.7 postintervention, a statistically
5
4.5
4
POMS Anxiety Scale
3.5
3
2.5
4.6
2
1.5
1
1.7
0.5
0
Pre-intervention Post-intervention
95% confidence interval, t=5.5, df=19, p<0.001
F I G U R E 1 Change in mean anxiety score following 3-minute
mindfulness intervention
ERNST AND D'MELLO
significant difference in score. (95% confidence interval: 1.8-4.0,
t = 5.5, df = 19, P < .001).
The total preintervention symptom burden (as measured by the
COMPASS Form) was not correlated with the decrease in anxiety sub-
scores (sample correlation coefficient = .27, 95% confidence interval:
−0.2 to 0.6, t = 1.2, P = .25).
4 | DISCUSSION
The results of our study suggest that a 3-minute mindfulness exercise,
conducted in the context of a routine 30-minute psychiatrist office
visit, contributed to a statistically significant reduction in state anxiety
for patients suffering from psychotic disorders. Furthermore, patients'
baseline psychiatric symptom burden did not appear to influence the
benefit they derived.
These results provide support for the implementation of a low-
cost, low-risk intervention—mindfulness meditation—which may
improve outcomes for FEP patients. Although such integrative
approaches are not always routinely utilized in patients with psychotic
disorders, this suggests that ambulatory FEP patients may derive sub-
stantial benefit from brief meditation, regardless of their symptom
burden. Our study is unique in its analysis of reduction of state anxi-
ety in FEP patients, which has not been as robustly assessed in studies
of other proposed interventions. More research is needed, however,
on the association between anxiety symptoms in FEP and long-term
outcomes.
A potential weakness of this study is the relative paucity of evi-
dence supporting state anxiety (as measured by the POMS Anxiety
Scale) as a valid proxy for generalized anxiety symptoms. An additional
weakness is the lack of a control group, which could account for mul-
tiple possible confounding variables (eg, therapeutic benefit derived
from meeting with a psychiatrist, having a few minutes of respite dur-
ing an otherwise structured appointment, etc.). Lastly, our small sam-
ple size and lack of longitudinal data prevented us from assessing
significant developments in clinical outcome.
Future studies might benefit from following both an intervention
and control group, and assessing reductions in anxiety symptoms over
time. This could account for the possibility of initial increase in anxiety
as participants begin to experience a higher degree of awareness, and
the resultant chance of more acute cognizance of anxiety-provoking
stimuli (including physical signs of anxiety, paranoid ideation, etc.). As
participants acclimate to the practice and learn to achieve attentive-
ness without fusion—a target beyond mere “relaxation”—they may go
on to obtain substantial benefit. Ideally, future studies would incorpo-
rate qualitative data detailing participants' experiences with mindful-
ness. It may also be interesting to investigate whether reduction in
anxiety over time correlates with overall improvement in symptom
burden/global functioning.
Although further study is warranted to corroborate our findings
and substantiate their long-term clinical relevance, the apparent bene-
fit derived from a brief mindfulness intervention suggests that this
may be a useful practice in the outpatient psychiatry setting. The
505
treatment of patients following first episode psychosis involves many
challenging targets, oftentimes including impairing anxiety. Mindful-
ness meditation may be a valuable tool in offsetting this.
AC KNOW LEDG EME NT S
We would like to thank Subha Hanif (Michigan State University medi-
cal student) for her role in the development and implementation of
the study. We would also like to thank Catherine Adams, LMSW,
ACSW, CAADC (owner and Clinical Director of ETCH) for her work in
coordinating and facilitating the study, as well as Kelly Curtis
(Supported Employment & Education Specialist at ETCH) for his work
on data collection and analysis.
CONFLIC T OF INT ER E ST
The authors declare no conflicts of interest.
OR CID
Alycia F. Ernst https://orcid.org/0000-0001-8730-1612
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