Relationships between amount of post-intervention mindfulness practice and follow-up outcome variables in an acceptance-based behavior therapy for Generalized Anxiety Disorder: The importance of informal practice

In Study 1, the original trial showed maintenance of gains across follow-up time points for worry, clinician-rated GAD severity, and quality of life.

“The main results for study 1, which were reported by Roemer, Orsillo, and Salters-Pednault (2008), showed large magnitude improvements at post treatment and maintenance of gains across follow-up time points for worry, clinician-rated severity of GAD symptoms, and quality of life.”

• cites Roemer, Orsillo, and Salters-Pednault (2008) sourceSupported

In Study 2, the original trial showed maintenance of gains through the 6-month follow-up for worry, GAD severity, and quality of life.

“The main results for Study 2, which are reported by Hayes-Skelton, Roemer, and Orsillo (2013), showed significant improvements at post treatment and maintenance of gains through the 6-month follow-up time point for worry, severity of GAD symptoms, and quality of life.”

• cites Hayes-Skelton, Roemer, and Orsillo (2013) sourceSupported

In Study 1, the original trial showed large magnitude improvements at post-treatment for worry, clinician-rated GAD severity, and quality of life.

“The main results for study 1, which were reported by Roemer, Orsillo, and Salters-Pednault (2008), showed large magnitude improvements at post treatment and maintenance of gains across follow-up time points for worry, clinician-rated severity of GAD symptoms, and quality of life.”

• cites Roemer, Orsillo, and Salters-Pednault (2008) sourcePartly supported

  The Results (Maintenance of Treatment Response; page unavailable) report post-treatment improvements in worry, clinician-rated GAD severity, and quality of life, with gains maintained through follow-up. But the Discussion describes the controlled effect on quality of life as medium-sized and marginally significant, not large; the claim overstates that outcome. (LLM, conf=0.89)

  Experimental — accuracy not yet measured

The results suggest a potential mechanism for the maintenance of symptom gains and/or continued improvements in outcomes seen during follow-up periods across mindfulness and acceptance-based treatment studies.

“The results of the current study suggest a potential mechanism for the maintenance of symptom gains and/or continued improvements in outcomes seen during follow-up periods across mindfulness and acceptance-based treatment studies (Forman et al., 2012; Hofmann et al., 2010; Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2009; Vowles, McCracken, & O’Brien, 2011).”

• cites Forman et al., 2012 sourceNot checked — no full text of the source
• cites Hofmann et al., 2010 sourcePartly supported

  The Results and Discussion report that gains in anxiety and depression symptoms after mindfulness-based therapy were maintained at follow-up (median 12 weeks). They do not establish continued improvement during follow-up, and the Discussion footnote explicitly excludes Acceptance and Commitment Therapy from the analyses. The proposed mechanism is framed as a conclusion of the citing study, not a finding attributed to Hofmann et al. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites Powers et al., 2009 sourceNot checked — no full text of the source

• AssumptionRests on an assumption: Participants who provided follow-up data are representative of the treated population.
• AssumptionRests on an assumption: The outcome measures (CSR, PSWQ, QOLI) are valid indicators of GAD severity, worry, and quality of life in this population.

In the combined final time point sample from both studies, informal practice was significantly related to clinician-rated anxiety severity.

“When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In the combined sample, mindful breathing was significantly correlated with residual changes in quality of life (ρ(34) = −0.52, p = 0.002).

“For the combined sample, participants’ mindful breathing scores were significantly correlated with residual changes in worry [ρ(32)= −0.42, p = 0.02] and quality of life [ρ(34) = −0.52, p = 0.002].”

In the combined sample, informal mindfulness practice was significantly correlated with residual changes in quality of life (ρ(34) = −0.57, p < .001).

“Informal mindfulness practice scores were significantly correlated with residual changes in worry [ρ(32)= −0.49, p = 0.004], GAD severity [ρ(32) = −0.51, p = 0.003] and quality of life [ρ(34)= −0.57, p < .001].”

At the 6-month follow-up in Study 2, informal mindfulness practice had a non-significant medium effect size correlation with quality of life (ρ(23) = 0.36, p = 0.09).

“While not statistically significant, there was also a medium effect size for the correlation between informal mindfulness practice and quality of life [ρ(23) = 0.36, p = 0.09] at 6-month follow-up (Cohen, 1992).”

• cites Cohen, 1992 sourceNot checked — no full text of the source

In the combined sample, formal practice was not significantly related to any outcome variables.

“Formal practice scores were not significantly related to any outcome variables in the combined sample.”

At the 12-month follow-up in Study 2, mindful breathing had a non-significant medium-to-large effect size correlation with worry (ρ(17) = −0.45, p = 0.07).

“Finally, while not statistically significant, there were medium to large effect sizes for the correlations between mindful breathing and worry [ρ(17) = −0.45, p = 0.07] and GAD severity [ρ(17) = −0.38, p = 0.13], informal mindfulness practice and GAD severity [ρ(17) = −0.43, p = 0.08], and formal practice and quality of life [ρ(19) = 0.36, p = 0.13].”

In Study 2, at the 12-month follow-up, mindfulness of breath was significantly related to quality of life.

“at 12-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life and worry, and mindfulness of breath was significantly related to quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In the combined sample, informal mindfulness practice was significantly correlated with residual changes in worry (ρ(32) = −0.49, p = 0.004).

“Informal mindfulness practice scores were significantly correlated with residual changes in worry [ρ(32)= −0.49, p = 0.004], GAD severity [ρ(32) = −0.51, p = 0.003] and quality of life [ρ(34)= −0.57, p < .001].”

In the combined final time point sample from both studies, mindfulness of breath was significantly related to worry.

“When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In the combined final time point sample from both studies, mindfulness of breath was significantly related to quality of life.

“When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

At the 9-month follow-up in Study 1, informal mindfulness practice was significantly correlated with residual changes in quality of life (ρ(15) = 0.55, p = 0.04).

“At 9-month follow up informal mindfulness practice was significantly negatively correlated with residual changes in worry [ρ(15) = −0.55, p = 0.04], GAD severity [ρ(15) = −0.59, p = 0.02], and quality of life [ρ(15)= 0.55, p = 0.04].”

In the combined sample, informal mindfulness practice was significantly correlated with residual changes in GAD severity (ρ(32) = −0.51, p = 0.003).

“Informal mindfulness practice scores were significantly correlated with residual changes in worry [ρ(32)= −0.49, p = 0.004], GAD severity [ρ(32) = −0.51, p = 0.003] and quality of life [ρ(34)= −0.57, p < .001].”

At the 12-month follow-up in Study 2, mindful breathing had a non-significant medium-to-large effect size correlation with GAD severity (ρ(17) = −0.38, p = 0.13).

“Finally, while not statistically significant, there were medium to large effect sizes for the correlations between mindful breathing and worry [ρ(17) = −0.45, p = 0.07] and GAD severity [ρ(17) = −0.38, p = 0.13], informal mindfulness practice and GAD severity [ρ(17) = −0.43, p = 0.08], and formal practice and quality of life [ρ(19) = 0.36, p = 0.13].”

At the 12-month follow-up in Study 2, informal mindfulness practice was significantly positively correlated with quality of life (ρ(19) = 0.55, p = 0.016).

“At 12-month follow up, participants’ mindful breathing and informal mindfulness practice were significantly positively correlated with quality of life [ρ(19) = 0.65, p = 0.002 and ρ(19) = 0.55, p = 0.016, respectively].”

At the 12-month follow-up in Study 2, mindful breathing was significantly positively correlated with quality of life (ρ(19) = 0.65, p = 0.002).

“At 12-month follow up, participants’ mindful breathing and informal mindfulness practice were significantly positively correlated with quality of life [ρ(19) = 0.65, p = 0.002 and ρ(19) = 0.55, p = 0.016, respectively].”

At the 6-month follow-up in Study 2, informal mindfulness practice was significantly negatively correlated with residual changes in GAD severity (ρ(25) = −0.55, p = 0.005).

“At 6-month follow up, participants’ informal mindfulness practice scores were significantly negatively correlated with residual changes in GAD severity [ρ(25) = −0.55, p = 0.005] and worry [ρ(22)= −0.46, p = 0.03].”

At the 12-month follow-up in Study 2, informal mindfulness practice had a non-significant medium-to-large effect size correlation with GAD severity (ρ(17) = −0.43, p = 0.08).

“Finally, while not statistically significant, there were medium to large effect sizes for the correlations between mindful breathing and worry [ρ(17) = −0.45, p = 0.07] and GAD severity [ρ(17) = −0.38, p = 0.13], informal mindfulness practice and GAD severity [ρ(17) = −0.43, p = 0.08], and formal practice and quality of life [ρ(19) = 0.36, p = 0.13].”

At the 9-month follow-up in Study 1, formal mindfulness practice had a non-significant medium-to-large effect size correlation with GAD severity (ρ(15) = −0.44, p = 0.10).

“While not statistically significant, there was a medium to large effect size for the correlation between formal mindfulness practice and GAD severity [ρ(15)= −0.44, p=0.10] (Cohen, 1992).”

• cites Cohen, 1992 sourceNot checked — no full text of the source

In the combined final time point sample from both studies, informal practice was significantly related to quality of life.

“When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In Study 1, at the 9-month follow-up, the amount of informal mindfulness practice was significantly related to continued beneficial outcomes for clinician-rated anxiety severity.

“Results from Study 1 showed that at 9-month follow-up, amount of informal mindfulness practice was significantly related to continued beneficial outcomes for worry, clinician-rated anxiety severity, and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In Study 1, at the 9-month follow-up, the amount of informal mindfulness practice was significantly related to continued beneficial outcomes for worry.

“Results from Study 1 showed that at 9-month follow-up, amount of informal mindfulness practice was significantly related to continued beneficial outcomes for worry, clinician-rated anxiety severity, and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In the combined final time point sample from both studies, informal practice was significantly related to worry.

“When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In Study 2, at the 12-month follow-up, informal mindfulness practice was significantly related to continued beneficial outcomes for worry.

“at 12-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life and worry, and mindfulness of breath was significantly related to quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

At the 12-month follow-up in Study 2, informal mindfulness practice was significantly negatively correlated with worry (ρ(19) = −0.49, p = 0.048).

“Additionally, informal mindfulness practice was significantly negatively correlated with worry [ρ(19) = −0.49, p = 0.048].”

Formal mindfulness practice was not significantly related to outcomes in either study or in the combined sample.

“Formal practice was not significantly related to outcomes in either study, or in the combined sample.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In Study 1, at the 9-month follow-up, the amount of informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life.

“Results from Study 1 showed that at 9-month follow-up, amount of informal mindfulness practice was significantly related to continued beneficial outcomes for worry, clinician-rated anxiety severity, and quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

At the 9-month follow-up in Study 1, informal mindfulness practice was significantly negatively correlated with residual changes in worry (ρ(15) = −0.55, p = 0.04).

“At 9-month follow up informal mindfulness practice was significantly negatively correlated with residual changes in worry [ρ(15) = −0.55, p = 0.04], GAD severity [ρ(15) = −0.59, p = 0.02], and quality of life [ρ(15)= 0.55, p = 0.04].”

At the 9-month follow-up in Study 1, informal mindfulness practice was significantly negatively correlated with residual changes in GAD severity (ρ(15) = −0.59, p = 0.02).

“At 9-month follow up informal mindfulness practice was significantly negatively correlated with residual changes in worry [ρ(15) = −0.55, p = 0.04], GAD severity [ρ(15) = −0.59, p = 0.02], and quality of life [ρ(15)= 0.55, p = 0.04].”

At the 12-month follow-up in Study 2, formal practice had a non-significant medium-to-large effect size correlation with quality of life (ρ(19) = 0.36, p = 0.13).

“Finally, while not statistically significant, there were medium to large effect sizes for the correlations between mindful breathing and worry [ρ(17) = −0.45, p = 0.07] and GAD severity [ρ(17) = −0.38, p = 0.13], informal mindfulness practice and GAD severity [ρ(17) = −0.43, p = 0.08], and formal practice and quality of life [ρ(19) = 0.36, p = 0.13].”

At the 9-month follow-up in Study 1, formal mindfulness practice had a non-significant negative correlation with quality of life with a very small effect size (ρ(15) = −0.07, p = 0.80).

“All relationships were in the expected directions except for the relationship between formal mindfulness practice and quality of life, which showed a non-significant negative correlation with a very small effect size [ρ(15) = −0.07, p = 0.80].”

In Study 2, at the 6-month follow-up, informal mindfulness practice was significantly related to continued beneficial outcomes for anxiety severity.

“Similarly, in Study 2, at 6-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for anxiety severity and worry”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In Study 2, at the 6-month follow-up, informal mindfulness practice was significantly related to continued beneficial outcomes for worry.

“Similarly, in Study 2, at 6-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for anxiety severity and worry”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

At the 6-month follow-up in Study 2, informal mindfulness practice was significantly negatively correlated with residual changes in worry (ρ(22) = −0.46, p = 0.03).

“At 6-month follow up, participants’ informal mindfulness practice scores were significantly negatively correlated with residual changes in GAD severity [ρ(25) = −0.55, p = 0.005] and worry [ρ(22)= −0.46, p = 0.03].”

In Study 2, at the 12-month follow-up, informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life.

“at 12-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life and worry, and mindfulness of breath was significantly related to quality of life.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In the combined sample, mindful breathing was significantly correlated with residual changes in worry (ρ(32) = −0.42, p = 0.02).

“For the combined sample, participants’ mindful breathing scores were significantly correlated with residual changes in worry [ρ(32)= −0.42, p = 0.02] and quality of life [ρ(34) = −0.52, p = 0.002].”

Informal practice showed the most consistent findings across studies and outcome variables.

“Informal practice showed the most consistent findings across studies and outcome variables.”

The relationships at 12 months remained stronger even when re-running the analyses at the 6-month follow-up with just those 19 individuals included in the original 12-month follow-up analyses.

“The relationships at 12-months remained stronger even when re-running the analyses at the 6-month follow-up with just those 19 individuals included in the original 12-month follow-up analyses.”

The remaining studies (three with MBSR participants and one following a 10-day intensive mindfulness meditation retreat) did not find significant relationships between amount of post-intervention practice and longer-term outcomes.

“The remaining studies, three with participants in MBSR programs (Davidson et al. 2004; Kabat-Zinn et al. 1987; 1992) and one following a 10-day intensive mindfulness meditation retreat (Ostafin et al. 2006), did not find significant relationships between amount of post-intervention practice and longer-term outcomes.”

• cites Davidson et al. 2004 sourceNot checked — no full text of the source
• cites Kabat-Zinn et al. 1987; 1992Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Ostafin et al. 2006 sourceNot checked — no full text of the source

In that meta-analysis, 13 of the 24 studies that examined the relationship between amount of practice and outcomes found that more practice was associated with better outcome.

“Thirteen (54%) of the 24 studies that did examine this relationship found that more practice was associated with better outcome”

• cites Vettese et al. (2009) sourceNot checked — no full text of the source

In the reviewed studies, methods of quantifying practice levels varied widely.

“however, methods of quantifying practice levels varied widely.”

Informal mindfulness practices are important tools for continued beneficial clinical outcomes following treatment for people with a principal diagnosis of GAD.

“These findings support the further study of informal mindfulness practices as important tools for continued beneficial clinical outcomes following treatment for people with a principal diagnosis of GAD.”

• AssumptionRests on an assumption: The single-item self-report questions validly and accurately measure the amount of formal, informal, and mindful breathing practice over the reported period.

In particular, measurements of informal practice were rarely included.

“In particular, measurements of informal practice were rarely included.”

In a meta-analysis of mindfulness-based group intervention studies, fewer than 25% of the 96 included studies provided data on the relationship between amount of reported practice and outcomes.

“A meta-analysis of mindfulness-based group intervention studies by Vettese et al. (2009) found that fewer than 25% of the 96 studies included in their analysis provide data on the relationship between amount of reported practice and outcomes.”

• cites Vettese et al. (2009) sourceNot checked — no full text of the source

These findings provide preliminary support for the ways that mindfulness is incorporated into ACT, DBT, and other ABBTs, in which formal practice is not emphasized as heavily as in MBSR and MBCT.

“These findings provide preliminary support for the ways that mindfulness is incorporated into ACT, DBT, and other ABBTs, in which formal practice is not emphasized as heavily as in MBSR and MBCT.”

• AssumptionRests on an assumption: Participants who provided follow-up data are representative of the treated population.
• AssumptionRests on an assumption: The outcome measures (CSR, PSWQ, QOLI) are valid indicators of GAD severity, worry, and quality of life in this population.

This study may be the first to examine these relationships in an individual acceptance-based behavioral treatment for people with a principal diagnosis of GAD and a range of comorbid diagnoses.

“This study may be the first to examine these relationships in an individual acceptance-based behavioral treatment for people with a principal diagnosis of GAD and a range of comorbid diagnoses.”

These results support previous findings that mindfulness practice amounts were related to levels of outcome variables during post-treatment periods on measures of anxiety.

“These results support previous findings that mindfulness practice amounts were related to levels of outcome variables during post-treatment periods on measures of anxiety (Gross et al., 2004).”

• cites Gross et al., 2004Not checked — no full text of the source

• AssumptionRests on an assumption: Participants who provided follow-up data are representative of the treated population.
• AssumptionRests on an assumption: The outcome measures (CSR, PSWQ, QOLI) are valid indicators of GAD severity, worry, and quality of life in this population.

The sample is racially homogeneous, precluding generalizations to more diverse populations.

“The sample is small and racially homogeneous, increasing the risk of making Type II errors and precluding generalizations to more diverse populations, respectively.”

Given the experiential nature of such treatments, informal practice and mindful breathing in daily life may help facilitate longer-term symptom improvements by helping clients continue to engage experientially with their thoughts and emotions in daily life situations.

“Given the experiential nature of such treatments, informal practice and mindful breathing in daily life may help facilitate longer-term symptom improvements in these treatments by helping clients continue to engage experientially with their thoughts and emotions in daily life situations.”

The sample is small, increasing the risk of making Type II errors.

“The sample is small and racially homogeneous, increasing the risk of making Type II errors and precluding generalizations to more diverse populations, respectively.”