Journal of Affective Disorders 282 (2021) 58–68

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

A randomized controlled trial of mindfulness-based cognitive therapy vs

stress management training for obsessive-compulsive disorder
Sonal Mathur, PhD a, Mahendra P Sharma, PhD a, Srinivas Balachander, MD b,
Thennarasu Kandavel, PhD c, YC Janardhan Reddy, DPM MD b, *
a
Department of Clinical Psychology, National Institute of Mental Health & Neuro Sciences (NIMHANS), Bangalore, India
b
Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, National Institute of Mental Health & Neuro Sciences (NIMHANS), Bangalore, 560029, India
c
Department of Bio-Statistics, NIMHANS, Bangalore, India

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Recently, mindfulness-based therapies have emerged as a treatment modality for OCD, but there is
Obsessive-compulsive disorder sparse controlled data. We report the efficacy of mindfulness-based cognitive therapy (MBCT) in treating OCD in
Mindfulness comparison with stress management training (SMT).
Mindfulness based cognitive therapy
Methods: 60 outpatients with DSM-IV-TR OCD attending a specialty OCD clinic were randomly assigned in 1:1
Randomized controlled trial
ratio to either MBCT (n=30) or SMT (n= 30). Both the groups received 12 weekly sessions of assigned inter­
vention. An independent blind rater assessed the primary outcome measure at baseline and at the end of 12
weeks.
Results: Significantly greater proportion of patients responded to MBCT than to SMT (80% vs. 27%, P <0.001). In
the linear mixed-effects modelling for intent-to-treat analysis, there was a significant reduction in the illness
severity measured using the Yale-Brown Obsessive-Compulsive Scale, obsessive beliefs of ‘responsibility/threat
estimation’ and ‘perfectionism/intolerance of uncertainty’ measured using the Obsessive Beliefs Questionnaire
and anxiety.
Limitations: Small sample size with a relatively high attrition in the control group. Lack of a cognitive behaviour
therapy (CBT) control group.
Conclusions: Mindfulness-based cognitive therapy is efficacious in the treatment of OCD. Future studies should
compare MBCT with CBT in larger representative samples and also examine the sustainability of change in
longitudinal studies.

Introduction Mindfulness-based therapies have a potential to reduce refusal and

Cognitive-behaviour therapy (CBT) involving exposure and response
prevention (ERP) is the psychotherapeutic treatment of choice for OCD
(NICE guideline (The National Institute for Health and Care & Excel­
lence), 2005). It often involves co-administration of cognitive therapy
aimed at modifying OCD related fear structure and dysfunctional beliefs
(McKay et al., 2015). However, exposure-based treatment can be very
demanding and anxiety provoking resulting in high refusal (Abramo­
witz et al., 2003a; Abramowitz and Schwartz, 2006) and drop-out rates
(Abramowitz et al., 2003b; Abramowitz and Schwartz, 2006; Pinto
et al., 2006). A recent meta-analysis reported a mean refusal rate and
attrition (drop-out) rate of 15% each (Öst et al., 2015)
attrition rates (Didonna, 2009; Strauss et al., 2018) and are found to be
acceptable (Leeuwerik et al., 2020) In the recent years,
mindfulness-based interventions have shown to be beneficial in the
treatment of OCD. The usefulness of these therapies has been demon­
strated in case reports (Alizadeh and Mohammadi, 2014; Fisher and
Wells, 2008; Goyal, 2004; Kumar et al., 2016; Sharma et al., 2012;
Twohig et al., 2006; Wilkinson-Tough et al., 2010), open label trials
(Hanstede et al., 2008; Kumar et al., 2016; Wahl et al., 2013) and in two
randomized controlled trials (Key et al., 2017; Külz et al., 2019).
Mindfulness-based interventions have also been found to be acceptable
(Hale et al., 2013) and useful in both dealing with obsessions as well as
reducing compulsions (Hertenstein et al., 2012).

* Corresponding author.
E-mail addresses: sonalmathurin@gmail.com (S. Mathur), sharma.mahendra81@gmail.com (M.P. Sharma), srinivasbalachander@gmail.com (S. Balachander),
kthenna@gmail.com (T. Kandavel), ycjreddy@gmail.com (Y.J. Reddy).

https://doi.org/10.1016/j.jad.2020.12.082
Received 17 August 2020; Received in revised form 12 November 2020; Accepted 22 December 2020
Available online 27 December 2020
0165-0327/© 2021 Elsevier B.V. All rights reserved.
S. Mathur et al.
Two randomized controlled trials have shown beneficial effects of
mindfulness-based cognitive therapy (MBCT) as an augmentation ther­
apy (Key et al., 2017; Külz et al., 2019). Kulz et al. adapted an 8-session
mindfulness based cognitive therapy (MBCT) depression treatment
program for patients with OCD (Külz et al., 2014). The therapy consisted
of training in mindfulness through various meditation techniques along
with regular home practice aimed at increasing awareness towards
bodily sensations, thoughts and emotions. The MBCT was used as an
augmentation therapy for residual symptoms of OCD after CBT. MBCT
was superior to psychoeducation in reducing self-reported OCD symp­
toms (but not on the YBOCS), obsessive beliefs and quality of life. In
another similar study, MBCT was compared with wait-list controls in
patients continuing to have symptoms after a CBT trial and found MBCT
to reduce OCD symptoms, depression, anxiety and obsessive beliefs
along with improvement in mindfulness skills (Key et al., 2017). How­
ever, in a pilot randomized controlled trial, mindfulness-based ERP was
not superior to ERP in improving symptom severity (Strauss et al.,
2018).
In an open label trial from our centre, mindfulness-integrated
cognitive behaviour therapy (MICBT) was efficacious in the treatment
of patients with predominantly obsessions (Kumar et al., 2016). In this
study, 27 patients with few or no overt compulsions received 12-16
sessions of MICBT, of which 18 (67%) achieved remission,
post-treatment [55% reduction in the Yale-Brown Obsessive Compulsive
Scale (Y-BOCS) severity score) (Goodman et al., 1989b)]. Therapy
consisted of training in mindfulness sitting, psychoeducation about OCD
and cognitions associated with OCD. This was followed by ERP sessions
utilizing mindfulness skills learnt by the client during initial sessions.
Though mindfulness-based therapies have, to some extent, demon­
strated efficacy in treatment of OCD, further research employing ran­
domized controlled design is required to establish their efficacy in the
treatment of OCD. The MBCT for OCD is a structured programme
designed to encourage deliberate, non-evaluative contact with the pre­
sent moment and the mechanisms of exposure, acceptance, and cogni­
tive change are central to this approach (Shapiro et al., 2006).
Mindfulness therapeutic approaches emphasize the role of individual as
an impartial observer of their own mental processes, including thoughts
and emotions. This is especially important in dealing with intrusive and
unpleasant thoughts, as well as ruminative patterns of thinking. MBCT
combines mindfulness exercises with elements of cognitive therapy
(Külz et al., 2014; Segal et al., 2002) with a focus on mindful exposure
and not on response prevention; it aims at bringing about cognitive and
behavioural change through awareness of own faulty cognitions and
attentional biases (Didonna, 2009).
In this study, we examined the efficacy of a 12-session structured
MBCT in treatment of OCD by employing a randomized-controlled
design. MBCT differs from metacognitive behaviour therapy in that in
the latter the exclusive focus is on addressing metacognitions underlying
intrusions and rituals by guided questioning, behavioural experiments,
response commission and detached mindfulness (Melchior et al., 2019)
whereas in the former, the focus is exclusively on applying mindfulness
techniques that encourage an open, non-judgemental awareness and
acceptance of symptoms (Didonna, 2009). Stress Management Training
(SMT), a 12-session structured programme (Davis et al., 2008) effective
in reducing anxiety and depression was used as a control, as has been
done in other studies of CBT in OCD (Lindsay et al., 1997; Simpson et al.,
2008; Whittal et al., 2010). SMT has not been shown to be beneficial in
reducing symptom severity in OCD demonstrating that non-specific as­
pects of therapeutic process are unhelpful in OCD (Lindsay et al., 1997;
Marks et al., 1975; Simpson et al., 2008). We employed SMT similar to
that employed in two previous studies to control for attention, time, and
other non-specific aspects of psychotherapy (Lindsay et al., 1997;
Simpson et al., 2008). We hypothesized that MBCT would be more
effective than SMT in treating patients with OCD.
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Journal of Affective Disorders 282 (2021) 58–68
Materials and methods
Sample
Sixty patients with a primary diagnosis of OCD were recruited from
outpatient mental health services of the National Institute of Mental
Health and Neurosciences (NIMHANS), Bangalore, India over a period of
16 months from April 2014 to August 2015. Fig. 1 shows the participant
flow and the study procedure. The NIMHANS Ethics Committee
approved the study for ethical aspects. The study was registered under
the Clinical Trials Registry- India (CTRI) (registration number: CTRI/
2016/01/006523). Participants gave written informed consent to
participate in the study. We included patients with DSM-IV-TR diagnosis
of OCD having a Y-BOCS total score ≥ 20 educated at least up to tenth
standard and aged between 18-50 years. We employed a Y-BOCS cut-off
score of 20 because there is some evidence that those with less than that
score may not be significantly impaired (Eisen et al., 2006). Patients
with comorbid psychosis, bipolar disorder, current psychoactive sub­
stance/alcohol dependence, history of neurological illness, history of
having undergone structured psychotherapy for OCD in the past one
year and not being on stable doses of serotonin reuptake inhibitors
(SRIs) for at least two months led to exclusion from the present study.
Randomization
Patients were allocated in 1:1 ratio to either the MBCT or the SMT
group based on random numbers table. Sequentially numbered opaque
sealed envelopes method was used for concealment of random
allocation.
Assessments
All patients underwent extensive diagnostic evaluation by the first
author which were confirmed by the senior clinician of the OCD clinic
(last author) after reviewing the clinical history and the data from the
Mini International Neuropsychiatry Interview (MINI; Sheehan et al.,
1998) and the Structured Clinical Interview for DSM-IV Axis
II–Personality Disorders (SCID-II; Maffei et al., 1997).
All patients were administered the following measures in English
language:
1 MINI (Sheehan et al., 1998) was used to confirm the diagnosis of
OCD and other common Axis I psychiatric comorbid conditions.
2 SCID-II (Maffei et al., 1997) was employed to diagnose any co­
morbid personality disorders.
3 Yale-Brown Obsessive Compulsive Scale (Goodman et al., 1989a,
1989b) includes a 15-item symptom checklist and a 10-item
measure of global severity of OCD. The 10-item scale yields
severity score of obsessions (range = 0–20), compulsions (range
= 0–20) and a total score (range = 0–40).
4 Clinical Global Impression scales (CGI) (Guy, 1976) assessed
global severity and improvement of obsessive-compulsive
symptoms.
5 Obsessive beliefs questionnaire-44 (OBQ-44); (OCCWG, 2001)
was used to assess three distinguishable domains of “obsessive”
beliefs, which are: inflated responsibility and the tendency to
overestimate threat, the need for perfectionism and certainty, and
the over importance and need to control thoughts. Each item is
rated on seven-point scale.
6 Hamilton anxiety rating scale (HARS); (Hamilton, 1959), a
clinician rated 14 item scale, was used to assess the physiological,
somatic and cognitive symptoms of anxiety. Each item is rated on
a 5-point scale, ranging from 0 (not present) to 4 (severe).
7 Montgomery-Asberg Depression Rating Scale (MADRS) (Mont­
gomery and Asberg, 1979) is a clinician rated 10 item scale, with
7 point scoring range. It assesses core symptomatology of
S. Mathur et al.
Fig. 1. Consolidated Standards of Reporting Trials (CONSORT 2010) Flow Diagram for Study Procedure and Participant Flow
MBCT=Mindfulness Based Cognitive Therapy; SMT= Stress Management Training.
depressive illness including associated anxiety. In the present
study, it was used to assess symptom severity of depression.
8 Acceptance and Action Questionnaire II (AAQ II) (Bond et al.,
2011) is a 10 item self-administered measure. The items are rated
on a 7-point Likert-type scale from 1 (never true) to 7 (always
true). In the current study, this scale was used to assess psycho­
logical flexibility.
9 Freiberg Mindfulness Inventory (FMI) (Walach et al., 2006) is a
14 item self-administered inventory rated on a 4-point scale. It is
a measure of mindfulness as a trait or as a target of clinical in­
terventions. This scale was used to assess mindfulness skills.
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Journal of Affective Disorders 282 (2021) 58–68
10 Work and Social Adjustment Scale (WSAS) (Mundt et al., 2002) is
a 5 item self-report scale of functional impairment attributable to
an identified problem. Score ranges from 0-40, stable across
different modes of administration and for at least 2-week interval
period in absence of any intervention. It was used in the present
study to assess impairment in work and social life.
11 World Health Organization Quality of Life Assessment (WHO­
QOL-BREF) (Power et al., 1999) contains 26 items, which
constitute 4 domains, physical health, psychological health, so­
cial relationship and environment. It is a self-administered scale.
Additionally, two items assess overall quality of life and general
S. Mathur et al.
health. It has been used in different cultural settings including
India, and the observation was found to be comparable across
cultures. In the current study, this scale was used to assess the
overall quality of life and the quality of life across different
domains.
12 Behavioural Analysis (McGinn and Sanderson, 1999) was used to
elicit information about the antecedent and maintaining factors
of obsessions and compulsions.
13 Homework Compliance Scale (Primakoff et al., 1986) is a two
item scale which includes degree of homework compliance and
quality of homework compliance, developed by Primakoff,
Epstein & Covi (1986). We employed the degree of homework
compliance alone to monitor the compliance of participants to
the therapeutic programme. Quality of homework compliance
was dropped since we found it was hard to determine accurately
the quality in both the treatment groups during the piloting
phase. Degree of compliance was assessed after each session by
the therapist on a 6-point scale ranging from ‘1’ (made no efforts
to carry out homework assignments) to ‘6’ (did more of the
assigned homework than was planned).
An independent trained blind assessor, a senior clinician expert in
assessing OCD patients rated the participants on the primary outcome
measures, which are the Y-BOCS (Goodman et al., 1989b) severity and
CGI rating scale (Guy, 1976) at baseline, and at post-intervention.
Outcome measures
Primary outcome measure was response to treatment. Response was
defined as ≥ 35% reduction in the YBOCS total score compared to
baseline, plus a score of 1 (very much improved) or 2 (much improved)
on the CGI-I (Mataix-Cols et al., 2016). Secondary outcome measures
included ‘clinically significant change’ (Jacobson and Truax, 1992) and
change in mean scores of the YBOCS, CGI-S, OBQ, HARS, MADRS,
mindfulness, QOL and WSAS from baseline to post-intervention
Treatment
All participants were on stable doses of SRI medication for at least
two months prior to entry into the study and their medication dosage
was not altered during the course of the study. Those participants who
were not on medication during entry into the study remained
medication-free for the duration of the study. No additional treatments
were given to patients other than continuing medications in the same
dose and the study intervention.
Participants in the MBCT group (n=30) underwent 12 individual
sessions of Mindfulness Based Cognitive Therapy, and participants in the
SMT group (n=30) also underwent 12 individual sessions of Stress
Management Training. For both groups, sessions were delivered once a
week for a total duration of 12 weeks, the duration of MBCT sessions was
35-40 minutes while the duration for SMT sessions was 25-30 minutes.
The first author, a clinical psychologist, having post-graduate de­
grees in MA (psychology) and MPhil (Clinical Psychology) and pursuing
doctoral course administered both CBT and MBCT. She was trained in
administering CBT and MBCT during MPhil course of 2 years; and during
the conduct of the study, was supervised by the senior clinical psy­
chologist expert in administering CBT and mindfulness based therapy
(MPS, second author) who reviewed the individual session notes of all
patients based on a separate checklist of therapy components for MBCT
and SMT. In addition, audio recordings of 5 patients in each group were
reviewed to ensure components of the two treatments were effectively
delivered.
MBCT
Mindfulness Based Cognitive Therapy (MBCT) for OCD is a set of
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Journal of Affective Disorders 282 (2021) 58–68
techniques designed to encourage deliberate, non-judgmental contact
with events that encourage being in the here and now. Integral to this
technique are mechanisms of exposure, acceptance and cognitive
change (Shapiro et al., 2006). MBCT sessions consisted of education
about OCD and common cognitive distortions, mindfulness training
through meditation and practice in daily life. This was followed by
regular self-monitoring of cognitive distortions and response to obses­
sions, retraining of attention and staying in psychological contact with
obsessions. During psychological contacting exercise, participants were
encouraged to use mindfulness skills learnt by them but were not asked
to prevent any compulsive response. For home practice, participants
were asked to practice mindfulness skills, monitor occurrence of ob­
sessions and their response, attention retraining exercises and psycho­
logical contacting. The details of the sessions are given in Box 1.
In the present study, MBCT was delivered in a structured 12-session
program. In sessions 1 and 2, patients were educated about the nature of
illness as well as the factors that maintain and increase the symptoms
and nature of common cognitive distortions. As home practice, patients
were given a table to monitor their obsessions, associated cognitive
distortions and at what time they were able to recognize the cognitive
distortions. Patients were also encouraged to be mindful while doing
daily activities (mindful eating, mindful walking, mindful brushing and
so on). From session 3 onwards, they were taught mindfulness sitting
and breathing meditation and were asked to practice these mindfulness
meditation techniques at home. These exercises were followed by
practice in formal attentional retraining in session 5, where the patient
was asked to set aside a specific time do a task requiring concentration
(studies or work related) and consciously practice keeping attention on
task at hand and bringing attention back if it wanders. From session 6,
Perceptive Experience Validation exercises were taught in the session
and were told to practice them at home by focusing on their real expe­
riences (what they can see, hear, smell, touch and taste) rather than on
unwanted thoughts and feelings (obsessions). This exercise was done in
order for the patient to distance themselves from their thoughts and
feelings. Psychological contact exercises were done in each session from
session 5 onwards in a progressive manner and also given for home
practice. From session 4 onwards, patient was exposed to a situation
leading to obsessions and asked to observe and recognize their inner
experiences of thoughts and feelings. They were not asked to prevent
compulsions at any point but just to observe and recognize if they did
perform compulsions. The purpose of these exercises is for the patient to
stay in touch with all experiences, including the unpleasant experiences
associated with obsessions and performance of compulsions.
SMT
SMT included 12 sessions of stress management skills such as pro­
gressive muscle relaxation, creative and positive visualization, problem
solving skills, assertiveness skills and goal setting (Box 2). Cognitive
restructuring, ERP and mindfulness techniques were part of the SMT.
Rationale given to patients was that the life stressors can trigger/worsen
OCD and that the management of stress would reduce stress and thereby
may help in the reduction of OCD symptoms. Participants were asked to
practice stress management skills / exercises at home on a daily basis.
Statistical analysis
We estimated the sample size requirement using GPower software
version 3.9.1 (Faul et al., 2007). As previous studies of
mindfulness-based interventions across psychiatric disorders that have
used a psychological placebo (such as stress management training) have
found effect sizes in the small to medium range , we used a conservative
effect size of 0.2 to estimate sample size. Using a repeated measures
analysis of variance model (2 groups, 2 time points), for a statistical
power of 0.8, an alpha error rate of 0.05, the required sample in each
group was found to be 24. To account for dropouts at the rate of 20%,
S. Mathur et al. Journal of Affective Disorders 282 (2021) 58–68

Box 1. Session Components of Mindfulness-Based Cognitive Therapy.

sample of 30 patients were taken in each group.
Baseline descriptive measures between the two groups were
compared using t-tests and chi-square tests, for the continuous and
categorical measures, respectively. For the primary outcome
(“response”, as defined above), we used a sensitivity analysis approach
by considering all possible “best” and “worst” case scenarios, wherein all
drop-outs are assumed to be either responders or non-responders in each
treatment group. For all the secondary outcomes, the intent-to-treat
analysis was conducted using a linear mixed model analysis. This
analysis takes into consideration all participants for whom at least one

62
S. Mathur et al.
Box 2. Components of Stress Management Training.
data point is available. A separate mixed-effects model was used for each
outcome measure (after controlling for relevant covariates), in which
Group x Time interaction term was included as the fixed-effects pre­
dictor, along with a random intercept for each subject. Effects sizes
(Cohen’s f2) were estimated for each of the outcome measures in the
linear mixed-effects analysis, using the F-statistic for each of the fixed-
effects terms (main effect of group, main effect of time and the
group*time interaction). The formula used to estimate the Cohen’s f2 has
been described (Thalheimer & Cook, 2002).
Jacobson & Truax (1991) methodology was used to calculate clini­
cally significant change, by calculating Reliable Change Index (RCI). The
cut-off point for RCI is ± 1.96 (p<0.05); any obtained value of RCI
greater than which would indicate a reliable change in the patient.
Results
Baseline characteristics
Socio-demographic and clinical characteristics of the sample are
shown in Table 1. At baseline assessment, the two groups did not differ
significantly on any relevant socio-demographic or clinical measures. A
majority were male, unmarried, employed, came from urban areas and
were on medication. The MBCT and the SMT groups did not differ
significantly with respect to baseline measures of illness severity,
obsessive belief domains, anxiety and depression, psychological
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Journal of Affective Disorders 282 (2021) 58–68
flexibility, mindfulness, work and social adjustment, and QOL domains
except in the social domain. All participants had moderate to severe
levels of symptoms severity.
With regard to symptom profile, the MBCT and the SMT groups did
not differ significantly on any YBOCS symptom categories (current):
aggressive [18 (60%) vs. 24 (80%), X2 = 2.857, P=0.091], sexual [11
(37%) vs. 10 (33%), X2 = 0.073, P=0.787), religious [16 (53%) vs. 14
(47%), X2 = 0.267, P=0.606], somatic [11 (37%) vs. 11 (37%), X2 =
0.000, P=1.000], contamination [15 (50%) vs. 13(43%), X2 = 0.268,
P=0.605], symmetry [13 (43%) vs. 18 (60%), X2 = 1.669, P=0.196],
pathological doubts [19 (63%) vs. 21 (70%), X2 = 0.300, P=0.584],
hoarding [1 (3%) vs. 4 (13%), Fisher’s P=0.353 and miscellaneous ob­
sessions [16 (53%) vs. 13 (43%), X2 = 0.601 P=0.438] and washing [16
(53%) vs. 16 (53%), X2 = 0.000, P=1.000], checking [21 (70%) vs. 19
(63%), X2 = 0.300, P=0.584], repeating [15 (50%) vs. 16 (53%), X2 =
0.067, P=0.796], counting [5 (17%) vs. 3 (10%), X2 = 0.577, P=0.448],
ordering [13 (43%) vs. 17 (57%), X2 = 1.057, P=0.302], collecting [2
(7%) vs. 4 (13%), X2 = 0.741, P=0.389] and miscellaneous compulsions
[28 (93%) vs. 29 (97%), X2 = 0.351, P=0.554].
Homework compliance
On the degree of homework compliance, the MBCT and the SMT
groups did not differ significantly on the average score of all sessions
although there was a trend towards poorer compliance in the SMT group
S. Mathur et al. Journal of Affective Disorders 282 (2021) 58–68

Table 1
Baseline socio-demographic and clinical characteristics of the OCD patients in the two groups.
Variable MBCT (n=30) Mean (SD) / N SMT (n=30) Mean (SD) / N t / Chi- P / Fisher’s
(%) (%) square exact

Age (in years) 27.57 (4.82) 28.93 (7.07) 0.87 0.39

No. of Years of Education 15.8 (1.21) 15.3 (1.32) 1.53 1.32
Sex (Male) 20 (66) 20 (66) 0.00 1
Marital Status (Unmarried) 18 (60) 18 (60) 0.00 1
Employment status Employed 29 (97) 26 (90) 1.96 0.602
Unemployed 1 (3) 4 (10)
Residing in an Urban Area 28 (93) 27 (90) 0.218 0.640
Age of onset of OCD, years 20.3 (6.93) 20.36 (7.18) -0.037 0.971
Duration of illness, years 7.28 (5.42) 8.5 (7.02) -0.751 0.456
CGI-S 4.43 (0.90) 4.63 (0.72)) -0.953 0.345
OBQ Responsibility/Threat estimation 69.57 (23.57) 67.70 (23.04) 0.310 0.758
Perfectionism/Intolerance of 85.00 (21.31) 87.27 (18.25) -0.443 0.660
uncertainty
Importance/Control of thoughts 49.53 (17.83) 51.90 (15.75) -0.545 0.588
Total 203.77 (59.47) 206.83 (50.49) -0.215 0.830
HARS total score 15.93 (6.73) 15.97 (6.73) -0.019 0.985
MADRS total score 7.74)9.67 (8.49) 12.67 (7.74) -1.430 0.158
Mindfulness (Freiburg Mindfulness Inventory) 32,83 (8.04) 30.53 (6.79) 1.197 0.236
Anxiety Avoidance Questionnaire II 34.80 (10.52) 30.60 (8.77) -0.720 0.475
Quality of life Physical 46.70 (10.66) 49.30 (13.46) -0.829 0.411
Psychological 45.63 (12.69) 42.80 (12.97) 0.855 0.396
Social 57.33 (16.91) 44.17 (18.34) 2.891 0.005
Environmental 62.47 (14.92) 60.07 (18.76) -0.548 0.586
Work and social adjustment, total score 23.03 (8.99) 27 (1.80) -1.666 0.101
Axis I Comorbidity (MINI - Any 10 (33) 11 (37) 0.73 0.78
Current)
Major Depressive Disorder 5 (17) 12 (40) 2.955 0.086
Dysthymia 0 (0) 3 (10) - -
Generalized Anxiety Disorder 1 (3) 2 (7) - 1.00
Panic Disorder 1 (3) 4 (13) - 0.350
Social Anxiety 3 (10) 2 (7) - 1.00
Personality disorders Any 4 (13) 11 (37) 4,.356 0.037
Anxious avoidant 1 (3) 1 (3) - 1.000
Obsessive-compulsive 3 (10) 6 (20) - 0.472
Dependent 0 2 (7) - 0.492
Schizoid 1 (3) 0 - 1.000
Borderline 0 4 (13) - 0.112
Lifetime SRI trials (n=47) 1.6 (0.96) 2 (0.97) -1.167 0.249
Duration of current SRI trial, months* 16.31 (18.45) 15.6 (17.79) 0.132 0.896
Current SRI Medication** Any SRI 21 (70) 25 (83) 1.491 0.222
Fluoxetine 6 (20) 6 (20) 0.000 1.000
Escitalopram 11 (37) 5 (17%) 3.068 0.080
Sertraline 2 (7) 5 (17) - 0.424
Fluvoxamine 1 (3) 3 (10)$ - 0.612
Paroxetine 0 2 (7) - 0.492
Clomipramine 1 (3) 4 (13)$ - 0.353
Current Antipsychotic Augmentation 2 (7) 4 (13) 0.185 0.671

MBCT – Mindfulness Based Cognitive Therapy; SMT – Stress Management Training; YBOCS – Yale-Brown Obsessive-Compulsive Scale; CGI-S – Clinical Global
Impression – Severity Scale; OBQ – Obsessive Beliefs Questionnaire; SRI – Serotonin Reuptake Inhibitor
* Most patients were on stable doses for more than 3 months (n = 42/47, 89%)
** Dose range of SRIs: Fluoxetine, 60-80mg/day; Sertraline 150-300mg/day, Fluvoxamine, 200 & 300mg/day, Escitalopram, 20-40 mg/day, Paroxetine 25 & 75mg/
day, Clomipramine 150-225mg/day
$ On a combination of fluvoxamine and clomipramine

[4.5 (SD, 1.1 vs. 3.93 (SD, 1.22), t = 1.876, p = .066)
Primary outcome
Significantly more number of patients in the MBCT group showed
response compared to that in the SMT group (Table 2). In view of high
drop-out rate in the SMT group compared to that in the MBCT group
(n=10 (33%) vs. n=3 (10%), Fig. 1), we analysed difference in the
outcome between the groups assuming that all drop-outs in the study are
responders; even then difference between the groups was statistically
significant [27/30 vs. 18/30, P = 0.017]. In the sensitivity analysis
(Table 2), significant improvement in the MBCT group was seen in all
scenarios except one. In this, all drop-outs in the MBCT group were
considered as non-responders and all of them in the SMT group as re­
sponders. Only a trend towards significance was noted in this [60% vs
40%, Chi-sq=1.94, p=0.159, RR= 1.71 (0.85–3.47)]. At post-
intervention, 23/27 (85%) of patients in MBCT group and 10/23
(50%) patients in SMT group showed clinically significant change.
In the regression analysis, only homework assignment (Adjusted R2
= 0.249, beta = 0.538, p =0.003) predicted percentage reduction in the
YBOCS. Other variables like baseline depression, baseline mindfulness
and baseline obsessive beliefs were not found to significantly predict
percentage reduction in the YBOCS severity.
Secondary outcomes
The results of the mixed-effects analysis for all the continuous sec­
ondary outcomes, after controlling for major depression, presence of any
personality disorder and degree of homework compliance are shown in
Table 3. On most outcome measures, there was a significant change over
time in both the groups, but the MBCT group showed significantly
greater improvement than the SMT from baseline to post-intervention

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S. Mathur et al. Journal of Affective Disorders 282 (2021) 58–68

Table 2 SMT may have some beneficial effect on obsessions but not on com­
Comparison between the two groups on primary outcome measure – Intention- pulsions. Our findings are partly supported by those of a previous study
to-treat analysis by worst-case and best-case scenarios and per-protocol of obsessionals without overt compulsions in which SMT was as good as
completers. CBT in reducing the severity of obsessions (Whittal et al., 2010). The
Scenario Number of Chi- p-value Risk counterintuitive finding was speculated to be due to several factors:
responders (% of n) Square Ratio eventual application of relaxation techniques to reduce anxiety trig­
(95% CI)
MBCT SMT gered by life-stressors (which may indirectly reduce the severity of ob­
Group Group sessions), distraction due to relaxation technique averting efforts at
Per-Protocol (Study 24/27 8/20 10.488 0.001 3.75 thought control and allowing a natural decay of the frequency of ob­
completers only) (89%) (40%) (1.34 – sessions, shifting energies to other life activities by goal setting, asser­
10.52) tiveness training and inadvertent disconfirmation of obsessive fears
Worst Case (All drop- 24/30 18/30 1.984 0.159 1.71
because of reduced general avoidance (Whittal et al., 2010). The
outs assumed as non- (80%) (60%) (0.85 –
responders in MBCT, 3.47) severity of compulsions reduced significantly in the MBCT group
responders in SMT) compared to the SMT group possibly because patients in the MBCT
Best Case (All drop-outs 27/30 8/30 22.22 <0.001 6.43 group learnt to handle compulsions using mindfulness techniques
assumed as responders (90%) (2 7%) (2.19 – whereas the SMT group did not have recourse to any special techniques
in MBCT, non- 18.87)
responders in SMT)
to handle compulsions. Future studies should further explore the utility
All drop-outs assumed as 27/30 18/30 5.689 0.017 3.00 of SMT and processes involved in its efficacy.
responders in both (90%) (60%) (1.06 – Modifying higher order cognitive processes like beliefs about
groups 8.49) importance and power of thoughts may have greater therapeutic success
All drop-outs assumed as 24/30 8/30 15.067 3.50
<0.001
than modifying lower order appraisals (Didonna, 2009). With MBCT,
non-responders in both (80%) (27%) (1.68 –
groups 7.31) there was a significant improvement in certain belief domains of the
OBQ suggesting that the treatment not only reduces illness severity but
MBCT – Mindfulness Based Cognitive Therapy; SMT – Stress Management
also changes underlying dysfunctional beliefs. Our finding of decrease in
Training
certain dysfunctional beliefs is in line with the recent studies of MBCT
(Cludius et al., 2020; Key et al., 2017; Külz et al., 2019, 2014). The
on the Y-BOCS (total and compulsion sub-score), the CGI-S, two domains studies by Kulz et al. examined the efficacy of MBCT in comparison with
of the OBQ (responsibility/threat estimation & perfectionism/intoler­ psychoeducation in patients who were partial responders or
ance of uncertainty) and the HARS. The two groups did not show sig­ non-responders to CBT (Cludius et al., 2020; Külz et al., 2019, 2014).
nificant difference with respect to the YBOCS obsession sub-score, They noticed improvement in beliefs and in self-rated OCD symptoms
importance/control of thoughts domain of OBQ, depression, mindful­ but not in clinician-rated symptoms both in the RCT (Külz et al., 2019)
ness, psychological flexibility, QOL and work and social adjustment. and in long-term follow-study of the same sample (Cludius et al., 2020).
Improvement in beliefs and also in symptoms was seen in another study
Discussion which employed MBCT as an augmenting therapy following incomplete
improvement with CBT (Key et al., 2017).
The findings of the current study show that 12-week structured In the context of efficacy of MBCT in treating OCD, it is important to
MBCT, a program of combination of mindfulness exercises and elements understand how it is different from the traditional CBT and meta­
of cognitive therapy, is efficacious in the treatment of OCD. In line with cognitive therapy. The MBCT focussed on bringing the patient to a being
the findings of previous studies, a significant reduction in severity of mode, of awareness and acceptance towards inner experiences as
OCD, obsessive beliefs and anxiety was noted for the participants in the opposed to doing mode, where individuals engage in cyclical pattern of
MBCT group, compared to the participants in the SMT group. (Hanstede ruminative thinking and counter-productive actions. This was achieved
et al., 2008; Kumar et al., 2016; Wahl et al., 2013) largely through mindfulness training and exercises to develop self-
An analysis of study-completers and all other outcome scenarios awareness and acceptance. Participation in MBCT increases mindful­
except the worst-case scenario demonstrates that MBCT is efficacious in ness skills, specially increased ability to be non-judgmental and non-
treating OCD (Table 2). The proportion of drop outs in the MBCT arm is reactive (Key et al., 2017). A non-judgmental attitude towards obses­
only 10% compared to 30% in studies of CBT (Olatunji et al., 2010; Öst sions may discourage suppression and avoidance of thoughts which
et al., 2015). However, the dropout rate in the SMT was three time could in turn facilitate habituation and a decreased reliance on com­
higher (33%). Dropout rates are often considered an important measure pulsions to reducer distress. In our study, there was a change in mind­
of treatment efficacy (Houghton et al., 2008) and are a standard measure fulness in both the groups but the groups did not differ significantly. A
in psychotherapy outcome studies (Moher et al., 2001). A high dropout few previous studies have reported improvement in mindfulness skills
rate in the SMT arm may be due to treatment failure and possibly due to following mindfulness based approaches (Didonna et al., 2019; Key
shorter sessions, but in the context of our study, it is important to be et al., 2017; Strauss et al., 2018). To detect statistically significant
aware that we did not ascertain the reasons for dropouts. changes between groups in mindfulness, psychological flexibility and
That MBCT is efficacious in treating OCD is reassuring since it will be QOL, a longer time may be required and may not be obvious immedi­
a useful addition to the armamentarium of psychological therapies for ately after completion of the therapy. It is also possible that we did not
OCD. The response rate is comparable to that seen with CBT (Herten­ detect significant changes in these parameters because the study was not
stein et al., 2012; Wahl et al., 2013). MBCT has some obvious advantages powered to detect changes in mindfulness and QOL.
over CBT involving ERP. Refusal and dropout rates for ERP are as high as The typical CBT module for OCD includes cognitive restructuring by
30% (Abramowitz et al., 2005, 2003b; Abramowitz and Schwartz, 2006) identifying and modifying dysfunctional beliefs such as inflated re­
because of dislike for exposure, unwillingness to tolerate anxiety during sponsibility and ERP (McKay et al., 2015), whereas the MBCT module
exposure and perceived worsening of symptoms (Abramowitz, 1997; includes primarily mindful exposure to obsessional stimuli and learning
Abramowitz et al., 2003a; Abramowitz and Schwartz, 2006). Addi­ to respond to obsessions by acceptance and a non-judgemental attitude.
tionally, it is hard to treat patients without overt compulsions with ERP Moreover, in MBCT, response prevention is not part of the therapy;
(Abramowitz et al., 2003a). patients learn to respond to compulsions mindfully. In metacognitive
Contrary to our expectations, SMT was as effective as MBCT in therapy, metacognitive beliefs about dangerousness, significance and
reducing severity of obsessions. It is counterintuitive, but possible that consequences of intrusions such as “fusion beliefs” and beliefs about the

65
S. Mathur et al. Journal of Affective Disorders 282 (2021) 58–68

Table 3
Comparison between the two groups on secondary outcome measures using Linear Mixed Effects (LME) modelling for intent-to-treat analysis.
Variable Predicted Mean Estimates (Standard errors or 95% CI) Mean Difference (95% CI) Main effect of group, Main effect of Time & Group*Time Interaction

Mindfulness SMT F value P-value Cohen’s f2

YBOCS Total Score

Baseline 26.24 (1.2) 26.46 (1.03) -0.22 (-3.14 - 2.7) 2.274 0.883 0.278
Post 13.73 (1.23) 17.51 (1.2) -3.78 (-6.97 - -0.6) 172.917 <0.001 2.421
Baseline - Post 12.51 (10.39 - 14.63) 8.95 (6.55 - 11.35) 3.56 (0.37 - 6.75) 4.791 0.033 0.403
YBOCS Obsessions Sub Domain Score
Baseline 13.6 (0.63) 13.46 (0.54) 0.14 (-1.4 - 1.69) 0.037 0.855 0.035
Post 8.26 (0.65) 8.68 (0.63) -0.42 (-2.1 - 1.27) 142.428 <0.001 2.197
Baseline - Post 5.34 (4.24 - 6.44) 4.78 (3.53 - 6.03) 0.56 (-1.1 - 2.22) 0.440 0.51 0.122
YBOCS Compulsions Sub Domain Score
Baseline 12.63 (0.67) 13 (0.58) -0.37 (-2.01 - 1.27) 6.747 0.661 0.478
Post 5.46 (0.69) 8.83 (0.68) -3.37 (-5.18 - -1.56) 125.722 <0.001 2.064
Baseline - Post 7.17 (5.85 - 8.49) 4.16 (2.68 - 5.65) 3 (1.03 - 4.98) 8.883 0.004 0.549
Clinical Global Impression - Severity
Baseline 4.45 (0.19) 4.64 (0.16) -0.19 (-0.65 - 0.27) 4.843 0.424 0.405
Post 2.84 (0.2) 3.59 (0.19) -0.75 (-1.25 - -0.25) 117.707 <0.001 1.998
Baseline - Post 1.61 (1.29 - 1.92) 1.05 (0.69 - 1.41) 0.56 (0.08 - 1.04) 5.287 0.026 0.423
OBQ Responsibility & Threat Estimation
Baseline 71.34 (5.35) 66.8 (4.57) 4.54 (-8.44 - 17.51) 0.676 0.495 0.151
Post 49.52 (5.46) 63.95 (5.23) -14.43 (-28.46 - -0.41) 13.557 <0.001 0.678
Baseline - Post 21.82 (13.12 - 30.51) 2.85 (-7.02 - 12.72) 18.97 (5.87 - 32.07) 8.053 0.006 0.522
OBQ Perfection & Intolerance of Uncertainty
Baseline 87.05 (4.85) 86.91 (4.14) 0.14 (-11.61 - 11.9) 1.673 0.981 0.238
Post 63.08 (4.95) 77.41 (4.72) -14.33 (-27 - -1.65) 31.940 <0.001 1.041
Baseline - Post 23.97 (16.29 - 31.65) 9.5 (0.77 - 18.23) 14.47 (2.89 - 26.05) 5.994 0.018 0.451
OBQ Importance and Need to Control Thoughts
Baseline 51.91 (3.85) 52.39 (3.28) -0.49 (-9.8 - 8.83) 1.212 0.919 0.203
Post 33.29 (3.93) 42.4 (3.73) -9.11 (-19.14 - 0.93) 37.984 <0.001 1.135
Baseline - Post 18.62 (12.6 - 24.64) 10 (3.15 - 16.84) 8.62 (-0.46 - 17.7) 3.462 0.069 0.343
Hamilton Anxiety Rating Scale
Baseline 17.9 (1.49) 16.65 (1.27) 1.26 (-2.36 - 4.87) 0.266 0.498 0.095
Post 7.34 (1.52) 10.33 (1.45) -3 (-6.9 - 0.9) 86.558 <0.001 1.713
Baseline - Post 10.57 (8.22 - 12.92) 6.31 (3.64 - 8.99) 4.25 (0.71 - 7.8) 5.519 0.023 0.433
Montgomery Äsberg Depression Scale
Baseline 11.35 (1.53) 12.93 (1.33) -1.58 (-5.34 - 2.19) 2.119 0.414 0.268
Post 4.91 (1.58) 8.12 (1.57) -3.21 (-7.36 - 0.94) 23.107 <0.001 0.885
Baseline - Post 6.45 (3.39 - 9.51) 4.81 (1.38 - 8.24) 1.64 (-2.94 - 6.21) 0.491 0.486 0.129
Freiberg Mindfulness Inventory
Baseline 32.62 (1.66) 30.39 (1.42) 2.23 (-1.79 - 6.26) 1.199 0.28 0.202
Post 35.35 (1.7) 33.44 (1.61) 1.91 (-2.42 - 6.24) 8.612 0.041 0.540
Baseline - Post -2.73 (-5.28 - -0.17) -3.05 (-5.96 - -0.15) 0.33 (-3.53 - 4.18) 0.028 0.868 0.031
Acceptance & Action Questionnaire II
Baseline 37.17 (2.25) 36.86 (1.91) 0.31 (-5.12 - 5.74) 0.002 0.911 0.007
Post 27.86 (2.29) 27.97 (2.16) -0.1 (-5.93 - 5.72) 49.340 <0.001 1.293
Baseline - Post 9.3 (5.95 - 12.66) 8.89 (5.07 - 12.71) 0.42 (-4.65 - 5.48) 0.026 0.873 0.030
Work & Social Adjustment Scale
Baseline 24.62 (2.21) 27 (1.89) -2.37 (-7.74 - 3) 1.269 0.389 0.207
Post 15.46 (2.26) 18.67 (2.18) -3.21 (-9.03 - 2.61) 37.942 <0.001 1.134
Baseline - Post 9.16 (5.48 - 12.85) 8.33 (4.15 - 12.51) 0.84 (-4.72 - 6.39) 0.087 0.769 0.054
QOL - Physical Domain
Baseline 45.67 (2.77) 49.84 (2.39) -4.17 (-10.93 - 2.6) 1.136 0.231 0.196
Post 53.92 (2.84) 56.26 (2.79) -2.34 (-9.74 - 5.07) 14.292 0.002 0.696
Baseline - Post -8.25 (-13.31 - -3.2) -6.42 (-12.12 - -0.72) -1.83 (-9.42 - 5.76) 0.224 0.638 0.087
QOL - Psychological Domain
Baseline 44.21 (2.96) 43.4 (2.52) 0.81 (-6.35 - 7.98) 0.001 0.825 0.006
Post 51.87 (3.02) 52.47 (2.88) -0.61 (-8.34 - 7.13) 21.195 0.002 0.848
Baseline - Post -7.66 (-12.37 - -2.94) -9.07 (-14.43 - -3.72) 1.42 (-5.69 - 8.52) 0.153 0.698 0.072
QOL - Social Domain
Baseline 56.27 (3.95) 46.2 (3.39) 10.07 (0.44 - 19.69) 1.577 0.044 0.231
Post 59.8 (4.05) 58.84 (3.93) 0.96 (-9.52 - 11.44) 9.324 0.319 0.562
Baseline - Post -3.54 (-10.43 - 3.35) -12.64 (-20.44 - -4.85) 9.11 (-1.25 - 19.47) 2.969 0.091 0.317
QOL - Environmental Domain
Baseline 59.85 (3.61) 60.17 (3.08) -0.32 (-9.07 - 8.43) 0.001 0.943 0.006
Post 67.6 (3.69) 67.03 (3.51) 0.58 (-8.86 - 10.01) 11.021 0.01 0.611
Baseline - Post -7.75 (-13.46 - -2.05) -6.86 (-13.34 - -0.37) -0.9 (-9.51 - 7.71) 0.042 0.839 0.038

MBCT – Mindfulness Based Cognitive Therapy; SMT – Stress Management Training;

YBOCS – Yale-Brown Obsessive-Compulsive Scale; OBQ – Obsessive Beliefs Questionnaire; QOL – Quality of Life

necessity of performing rituals are exclusively addressed along with
detached mindfulness (Wells, 2009) whereas in MBCT, they are not
exclusively addressed and focus is on mindful awareness and exposure,
acceptance and non-judgemental attitude (Külz et al., 2014).
Higher levels of homework compliance were found to be positively
associated with percentage improvement in YBOCS severity. Regardless
of the allocated groups, or the treatment condition, adherence to
homework and the quality of homework done by the participants has
emerged as the single predictor for improvement in the symptom
severity of OCD, that is, the primary outcome. Degree and quality of

66
S. Mathur et al.
homework compliance has consistently been found to significantly
predict treatment outcome in several other studies on treatment of OCD
(Anand et al., 2011; Simpson et al., 2008; Wheaton et al., 2016). Higher
degree of homework compliance may indicate better motivation for and
engagement with therapy. This indicates that higher degree and quality
of homework compliance leads to increased opportunities to further
therapeutic gains and understanding the therapeutic concepts better as
well as applying them regularly, thereby enhancing the learning.
Limitations
Our sample included patients who were symptomatic despite being
on an SRI (n= 47/60, 78%) suggesting some degree of non-response to
SRIs; therefore, findings may be generalizable to mostly patients who
are already on an SRI and not to drug-naïve or treatment-naïve patients.
We did not compare the efficacy of MBCT against an established treat­
ment modality for OCD, such as traditional CBT or ERP. A small sample
size is a limitation that needs to be kept in mind while interpreting our
findings. The sample size of the study was calculated by taking into
account only the primary outcome and thus it may have been small or
inadequate to be able to statistically analyse the outcome of all the
variables studied. The variables associated with therapeutic process
such as therapeutic alliance, treatment motivation, expectations from
treatment or the mechanisms of change specific to MBCT were not
assessed and analysed. Though the number of sessions received by both
groups was same, the duration of sessions was longer in the MBCT group
than in the SMT group. Lesser therapist contact may not have adequately
controlled for attention, and other non-specific psychotherapy effects
resulting in potentially inflated effect of MBCT. Shorter duration of
sessions, overrepresentation of personality disorders, along with non-
significant overrepresentation of depression and somewhat poorer de­
gree of homework compliance in the SMT group may have inflated the
benefit of MBCT. The sample for the study was primarily from an urban
background, with fairly high level of education which may make it
difficult in generalizing these results to a broader, more diverse, com­
munity sample.
Conclusions
The present study supports the findings from previous research that a
mindfulness-based therapy is efficacious in the treatment of OCD.
However, it is important to examine the sustainability of improvement
in longitudinal studies. Future research should aim to compare MBCT
against CBT with ERP, an established treatment for OCD in a larger
sample. It may be also pertinent to establish its efficacy in comparison
with CBT, in patients who are either drug-naïve or treatment naïve, to
determine if it can be recommended as a first-line treatment. CBT is now
recommended as the augmenting therapy of choice in patients who are
either partial responders or non-responders to SRIs; it may be worth­
while examining the role of MBCT in such patients as management of
treatment resistance in OCD continues to be a big clinical challenge.
There are many variations of mindfulness-based therapies; their relative
merits in comparison with CBT is a research priority. Finally, research
into the processes involved in the change during therapy would help in
understanding the mechanisms responsible for credible changes.
Declaration of Competing Interests
No conflicts of interest
Role of Contributors
SM: study conceptualization, design, data collection and drafting the
manuscript
MPS: conceptualization, design, supervision of therapy, final
approval of the manuscript
67
Journal of Affective Disorders 282 (2021) 58–68
SB: statistical analysis and data interpretation
TK: design, statistical analysis, data interpretation
YCJR: study conceptualization, design, data interpretation, revising
the manuscript critically for intellectual content, preparation and
approval of the final version
Submission declaration
All authors confirm that the work presented here has not been
published previously and is not currently being considered for publi­
cation elsewhere
Funding sources
Not funded; study performed as part of the doctoral work of the first
author
Data availability statement
The data may be obtained from the corresponding author upon
request
Acknowledgments
We acknowledge Prof. Paulomi Sudhir and Prof. M. Manjula of the
Department of Clinical Psychology, NIMHANS for their help toward the
conduct of the study
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