App-delivered mindfulness training eases anxiety

Mindfulness training (MT) delivered through an app (Unwinding Anxiety) significantly alleviates anxiety, a study has shown. Increases in psychological nonreactivity and reductions in worry mediate the effects of this app, which suggests a specific targeting of reinforcement learning.

“These findings demonstrate the clinical efficacy of MT as a digital therapeutic for individuals with anxiety,” the researchers said. “These results also link recent advances in our mechanistic understanding of anxiety with treatment development, showing that app-delivered MT targets key reinforcement learning pathways, resulting in tangible, clinically meaningful reductions in worry and anxiety.”

Sixty-five individuals with generalized anxiety disorder (GAD) were recruited through social media advertisements and randomly assigned during an in-person visit to receive treatment as usual (n=33) or treatment as usual plus app-delivered MT (n=32). The latter consisted of 30 modules to be completed over a 2-month period.

Finally, the researchers assessed associated changes in outcomes using self-report questionnaires at 1 and 2 months after treatment initiation. They used a modified intent-to-treat approach for the analysis.

Individuals in the MT group completed a median of 25 modules; 13 out of 28 (46 percent) participants completed the programme. At 2 months, the MT group also showed a significant decrease in anxiety (GAD-7) compared with the control group (67 percent vs 14 percent; median change in GAD-7, –8.5 vs –1.0, 95 percent confidence interval, 6–10; p<0.001). [J Med Internet Res 2021;23:e26987]

Increases in mindfulness at 1 month (nonreactivity subscale) mediated reductions in worry at 2 months (Penn State Worry Questionnaire; p=0.02), while decreases in worry at 1 month facilitated reductions in anxiety at 2 months (p=0.03).

“Our findings show that increases in mindfulness directly mediate the effects of app-delivered MT on reductions in worry,” the researchers said. “This may be the case possibly because of helping individuals step out of perseverative worry habit loops that are at the core of GAD and, in doing so, reduce their reinforcement.”

Of note, MT may stimulate decentering, a metacognitive capacity to observe items arising in the mind as mere psychological events. Decentering could help individuals disengage from perseverative worry habit loops that are perpetuated through reinforcement learning. [Behav Ther 2007;38:234-246; Cognit Ther Res 2015;39:228-235; Curr Opin Psychol 2019;28:198-203; Psychol Addict Behav 2013;27:366-379; Front Psychol 2018;9:1418]

The high prevalence of anxiety has exceeded the capacities of mental health services, and this gap had increased over the years, according to the researchers, noting that app-based digital therapeutics “offer a viable and practical route toward augmenting traditional mental healthcare and … serve as a first-line treatment. [Curr Psychiatry Rep 2018;20:44; World Psychiatry 2021;20:318-335]

“As integrative care models (eg, embedding psychiatric or psychological services within primary care clinics) gain momentum, one of the primary limitations is the cost and availability of trained therapists,” the researchers said.

“However, because 85 percent of the US population has a smartphone, digital therapeutics may be able to serve as the mobile component of an integrative care clinic at a low cost, filling in for the lack of physical space and trained mental health clinicians,” they added.